Submitted: 31 August 2022
Accepted: 27 September 2022
Published online: 4 April, TAPS 2022, 8(2), 83-85
https://doi.org/10.29060/TAPS.2023-8-2/PV2874

Janet Grant^1,2

¹Centre for Medical Education in Context (CenMEDIC), United Kingdom; ²University College London Medical School, United Kingdom

I. TO BEGIN WITH MY VIEW

Medical education is a social science which addresses how people learn and teach medicine. The practice of education and training is therefore fundamental to its epistemology, whereby knowledge, and so scholarship, derives from practice. Where that practice is subject to social, contextual and cultural factors, we must question whether the tenets that are put forward are generalisable beyond the context from which they were derived (Fendler & Cole, 2006). This lack of automatic generalisability has implications for both the scholarship of the medical educationalist, and for the relationship between medical educationalist and teacher. Where educational practice is primary, and is contextually informed, then the teacher, the practitioner of medical education, must be the leader in developing scholarship, while the medical educationalist can support that development by enabling each teacher, context or culture, to tell their own truth well (Grant & Grant, 2022). 

II. WHY IS THIS MY VIEW?

A. Scholarship and the Primacy of Practice

The term ‘scholarship’ implies special knowledge that is derived from research or academic analysis. While we can argue that learning has a research basis in educational and cognitive psychology, the same cannot be said of teaching. We can think, for example, of the churn of new teaching methods (sometimes erroneously presented as new ideas about learning) that sweep into medical education, find little evidence of consistent effect, and fade into the ever-expanding menu of teaching options. We can think of problem-based, task-based, case-based, resource-based, peer-assisted, blended, team-based, and e-learning, the flipped classroom, and more broadly, active learning and learner-centred learning. And there are more, changing with fashion and social values.

Are these changes based on generalisable knowledge derived from robust research? Although there might be published papers, they rarely constitute a consistent body of scholarly knowledge that enables claims about predictable effects of different teaching methods in different contexts. That is the nature of social science (Fendler & Cole, 2006). It is this lack of generalisability of the social practice of teaching that places the epistemology of medical education not in theories or fashion, but in widely variable, and contextually tailored, practice.

Although the practice of teaching is socially bound, we can say that the fundamental cognitive basis of learning, how knowledge is effectively organised in memory and accessed when needed, is the same for everyone. Knowing that short-term, working memory should not be overloaded, and that long-term memory should be well-organised with structured, generalisable and accessible knowledge, is the simple baseline against which a medical educationalist can ensure that teaching and learning methods are designed and judged. Many which demand complex processes (sometimes termed ‘learner-centred’) would fail that test.

There is a parallel literature demonstrating that the social, personal and interpersonal processes that cause knowledge to be stored and used effectively, and motor and cognitive skills to develop, are different depending on culture, content and context. Teaching that seems applicable and relevant in one cultural or content context may not apply in another. So it seems important to begin from practice, observe successes and problems, and build theories, if that seems helpful.

These uncertainties underpin our practice-based epistemology, where the teacher is the key person. Accordingly, we have argued (Grant & Grant, 2022) that medical education is not an academic discipline at all, but is an examination of instrumental practice, trying to relate educational activities to purposes, making its means relate to its ends, and making decisions about that on the basis of context and judgement. 

This view places the teacher at the heart and in the vanguard of relevant medical education development. This is social science where generalisable scholarship in teaching is difficult to attain. So, there is an ethical responsibility borne by those who claim to know what effective teaching is. 

This leads to the next question.

B. What might be the Relationship Between the Teacher and the Medical Educationalist?

Definitionally, I take a medical educationalist to be someone who claims special expertise by virtue of, for example, having completed a Master’s degree in health professions education. Some teachers have done this too, but most have not. Teachers, here, are the subject specialists who actively help others to acquire necessary knowledge and skill.

What might be the relationship between these two?

To answer this, we turn to Lawrence Stenhouse, a British educational thinker who sought to promote an active role for teachers in educational research and curriculum development. Stenhouse argued that the teacher might lead quality development, becoming an ‘extended professional’, supported by trained technical expertise: ‘It is not enough that teachers’ work should be studied: they need to study it themselves’ (Stenhouse, 1976, p143).

In this endeavour, the medical education specialist is a resource, knowing the theories and fashions, and their critiques, summarising where there is and is not evidence, guiding analysis, offering options in relation to the teacher’s practice. The teacher is an equal partner in this ‘mutually supportive co-operative research’ (Stenhouse, 1976, p159), learning to be a researcher, simply because knowledge comes from and is tested in its performance. The medical educationalist will be a crucial support in this process.

To hold this supporting role demands being critically informed about medical education theory and practice. Medical education seems replete with largely unexamined terms such as ‘adult learning’, ‘learner-centred’ or the oxymoronic ‘passive learning’; or with handy mnemonics, and frameworks that have ever-decreasing academic credibility such as ’learning styles’. Medical educationalists must be more securely rooted in the critical approach of social science, beyond the constantly metamorphosing rhetoric of medical education. That authenticity will be gained in equal partnership with teachers. 

Stenhouse’s position is unequivocal: the expert is the teacher, the practitioner who understands the individual context. The ‘teacher as researcher’ was Stenhouse’s ground-breaking view of the basis of rational educational development (Stenhouse, 1976, pp. 142-165).

How different is the implication of this view of the teacher, not as a person to be studied or developed, but the person who should be the scholar, reaching, and sharing, their own conclusions in their own classroom. Agency then belongs to the teacher who enacts the curriculum.

In this model, the role of the medical education specialist is to provide knowledge of developmental potential, and of how to develop practice-based, contextual scholarship around methods of reflective action research, perhaps. The medical educationalist is no longer the primary source of knowledge, or the impartial researcher, but is the means of supporting authentic practice development, helping each teacher to find their own truth.

C. And What of the Scholarship of Teaching?

The literature on the scholarship of teaching addresses its derivation in research and reflection on practice, and its use in theory building and educational development. In that literature, the meaning of scholarship in relation to actual teaching is ill-defined.

The importance of this for medical education is that scholarship can easily be thought of as the domain of those who have taken medical education as their speciality, rather than the domain of the teacher who is primarily a scientist or a clinician. This creates a particular relationship where ideas such as ‘faculty development’ suggest that the scholarship of teaching is garnered elsewhere and then shared with the teacher.

But I have argued that the scholarship of teaching will come from the experience of the teachers. Others argued, before me, that knowledge comes from social practice, and then returns to serve and enhance that practice (Mao, 1937). In that, there must be a mechanism for gathering that knowledge derived from social practice and returning it to practice. This may be the role of the medical educationalist, or of medical educationalists collectively, pooling their knowledge gained through working with teachers, reflecting their experience.

This role of gathering together knowledge generated in practice, is especially important in these days when the controversial idea of ‘globalisation of education’ often passes without critique. But ‘Globalisation initiatives must be tempered by ‘cultural humility’ in recognition of the likelihood that, rather than there being one exclusive, universal and ‘superior’ model, there may be many models of effective teaching and learning in medical education around the world’ (Wong, 2011, p. 1218). For Wong, in opposition to the neo-institutionalist, perhaps neo-colonialist, view, ‘…the culturalist perspective focuses on the enduring ability of different cultures and ways of knowing to re-interpret, transform and hybridise education practices to best suit local context’ (Wong, 2011, p. 2010).   

This view recognises those contextual imperatives: scholarship must derive from the domain of the teacher, supported, not driven, by the medical education specialist. This is true both of ideas on teaching methods, and of the theoretical and conceptual frameworks that shine and fade in parallel.

In this view, the teacher would become an extended professional who has ‘a capacity for autonomous professional self-development through a systematic self-study, through the study of the work of other teachers and through the testing of ideas by classroom research procedures’ (Stenhouse, 1976, p. 144). In other words, scholarship reverts to the teacher. Support for that scholarship belongs to the medical education specialist, working by the practitioner’s side, in the classroom, enabling that person to advance the contextual practice of medical education.

Note on Contributor

Janet Grant wrote the script, discussed it with Leo Grant and Professor Ahmed Rashid, and wrote the final version.

Acknowledgement

I would like to thank Leo Grant of CenMEDIC, London, and Professor Ahmed Rashid, of University College London Medical School, for their comments on this paper which helped me to express my personal view so much better than I could have done by myself.

Funding

There was no funding support accorded for this study.

Declaration of Interest

The author declares that there is no conflict of interest.

References

Fendler, L., & Cole, J. (2006). Why Generalisability is not Generalisable. Journal of Philosophy of Education, 40(4), 437–449. https://doi.org/10.1111/j.1467-9752.2006.00520.x

Grant, J., & Grant, L. (2022). Quality and constructed knowledge: Truth, paradigms, and the state of the science. Medical Education. https://doi.org/10.1111/medu.14871

Mao, Z. (1937). On Practice. https://www.marxists.org/reference/archive/mao/selected-works/volume-1/mswv1_16.htm

Stenhouse, L. (1976). An Introduction to Curriculum Research and Development. Heinemann.

Wong, A. K. (2011). Culture in medical education: Comparing a Thai and a Canadian residency programme. Medical Education, 45(12), 1209–1219. https://doi.org/10.1111/j.1365-2923.2011.04059.x

*Janet Grant
27 Church Street,
Hampton, Middlesex
TW12 2EB,
United Kingdom
Email: janet@cenmedic.net

Submitted: 15 July 2022
Accepted: 21 September 2022
Published online: 4 April, TAPS 2023, 8(2), 80-82
https://doi.org/10.29060/TAPS.2023-8-2/PV2842

Kevin Tan^1,2, Yang Yann Foo² & Nigel Choon Kiat Tan^1,2

¹Office of Neurological Education, Department of Neurology, National Neuroscience Institute, Singapore; ²Duke-NUS Medical School, Singapore

A program director of a one-year-old Singapore surgical residency programme reads a publication about a new model of feedback. The paper describes how a US medical school successfully trialled and implemented this new feedback model. Excited, she then tries to implement this new model in her residency programme. Unfortunately, this fails to change faculty and resident behaviour, with disgruntled faculty and residents, and poor take-up by the various surgical departments within her programme. Disappointed, she stops using the new feedback model after a year.

What happened? Why would an educational intervention about feedback, published as part of Scholarship of Teaching and Learning (SoTL) (Steinert, 2017), and successfully implemented in a US medical school, fail to take root in a Singapore surgical residency programme? Might failure to consider context have contributed?  A review of the publication showed that while descriptions of the feedback model and the educational outcomes were rich, descriptions of the medical school environment and the broader educational context of the US were sparse.

Might a richer description of context in the publication have helped readers understand the social and educational milieu from which the novel feedback model developed? And with that understanding of context, might a subsequent analysis of contextual differences between the publication and the residency programme’s dissimilar contexts have helped avoid this education setback? Fundamentally, did the lack of contextual descriptions lead to a myopic view of the educational intervention?

Let’s first examine SoTL, which is defined as “the description and dissemination of effective and novel teaching methods and strategies, in a research presentation or publication” (Steinert, 2017).  While standards for SoTL in health professions education (HPE) have been proposed (Glassick, 2000), including the need to describe goals, preparation, methods and results, there is scant mention of the need to describe the context within which the novel methods or strategies were operationalised or implemented. So while SoTL remains effective for disseminating novel teaching methods, the variable extent to which context is described (Bates & Ellaway, 2016) may result in challenges in implementing such methods in a different environment; key contextual enablers for successful implementation may have been inadequately described within the HPE SoTL literature. In contrast, the general education literature has long been aware of the importance of context in SoTL (Felten, 2013). There is therefore a blind spot in the HPE SoTL literature.

We next examine context. While we highlight rich descriptions of context for the value it brings to SoTL, we pause to reflect: how do we define context? Context can be difficult to define. A scoping review (Bates & Ellaway, 2016) concluded that one perspective was context as a “surrounding”, much like the layers of an onion, with a particular context playing a role as a mechanism influencing education outcomes. Employing these twin perspectives of “context as an environment surrounding an education activity”, and “context as a mechanism” (Bates & Ellaway, 2016) influencing said activity, we can then view context as surrounding and influencing the educational method, its implementation and its outcomes.

Given the many elements within the context that may influence outcomes, how do we then systematically identify and dissect these disparate elements? The analogy of an onion with surrounding layers (Bates & Ellaway, 2016) led us to consider Bronfenbrenner’s Ecological Systems theory (EST) (Bronfenbrenner, 1986). In EST, multiple systems (micro-, meso-, exo-, macro- and chrono-), much like layers of an onion, influence an individual’s learning. EST can be used to identify, dissect, and categorise contextual influences, and determine if they enable or inhibit educational activities.

In our scenario, the original SoTL work did not fully describe the context. Let us now imagine that the situation was clarified by us writing to the authors to learn more about their context. We are then rewarded with a rich, three-page description of their context. Using EST to dissect the differences between the US context of the intervention, versus the Singapore context of the residency programme, we now realise there were differences at multiple EST system levels, for example:

1. Microsystem: medical students vs residents as learners and feedback recipients, university faculty vs clinician faculty as feedback providers
2. Mesosystem: uniprofessional vs multiprofessional peers and colleagues, undergraduate vs postgraduate curricula
3. Exosystem: university vs clinical training environment, academic workload vs clinical workload
4. Macrosystem: cultures of medical school vs residency, cultures of university vs medical profession, societal cultures of the US vs Singapore
5. Chronosystem: historical perceptions of feedback and utility of feedback in the US vs Singapore

 

With these different EST system levels in mind, one can identify enablers and inhibitors to successful implementation of the published feedback model in Singapore:

1. Microsystem: residents and/or clinician faculty may be busy or distracted by concurrent clinical duties, thus less willing or able to deliver actionable feedback using the model, vs university lecturers who had dedicated time for feedback sessions
2. Mesosystem: while feedback was institutionalised in the US medical school as a longitudinal aspect of the curriculum since 10 years ago, allowing easier integration of a new model into a mature curricular element, adding a new feedback model into a one-year-old programme’s curriculum and implementing it added more stress to a new programme still in flux
3. Exosystem: the US medical school had several resources that the local programme did not. The American researchers had many dedicated teaching rooms for feedback provision to the medical students. In contrast, the surgical residents had to compete with other residents and users for fewer rooms in the local hospital that were also used for multiple clinical, administrative and research purposes. The university also had a mature e-portfolio system where faculty and students could review goals, milestones and progress to facilitate feedback provision, while the new residency programme did not.
4. Macrosystem: feedback was viewed positively by university faculty and students as a key learning activity, with the school taking pride in providing actionable feedback as part of its culture and values. The school’s Dean also publicly affirmed support for the new feedback model. In contrast, the new residency faculty were still unused to providing structured feedback, or inviting reflection as part of feedback; some even viewed feedback as a chore rather than as a vehicle for learning and improvement. The nascent feedback culture of the residency faculty had not fully taken root yet, unlike in the US school.
5. Chronosystem: Historical perceptions of feedback differed in the US vs Singapore, with feedback considered valuable for learning and improvement in the US. In Singapore however, feedback was viewed by some senior surgical faculty members as being useful only when mistakes were made by residents, whereupon forceful negative feedback was given by faculty to the resident in the name of patient safety, rather than for learning. These views from the local senior faculty were informed by their prior experiences as trainees in earlier training systems, leading to their rejection of the new feedback model as being “soft” and compromising patient safety.

 

With a rich description of context, and using EST as a tool, one can now see how the different system layers surround and envelope the faculty, residents and their feedback interaction. One can also see how contextual differences in these system layers (in the US vs Singapore) influenced the success or failure in implementation of the new feedback model. If rich contextual information was provided in the SoTL literature at the start then this information, considered with EST, might have helped the residency programme director avoid the implementation failure.

Successful understanding and application of SoTL in HPE thus relies not only on the six goals espoused by Glassick (Glassick, 2000), but also requires adequate descriptions of context. Readers can then understand contextual differences, use EST to compare and contrast it to their context, identify differences at various EST system layers and determine the potential influence of these differences.

Conversely, the general education literature emphasises that SoTL should be “grounded in context” (Felten, 2013). Felten explicitly states “… all SoTL is rooted in particular classroom, disciplinary, institutional, and cultural contexts” and that “any measure of good practice must account for both the scholarly and the local context where that work is being done” (Felten, 2013). The primacy of context is stated, clearly and unambiguously.

In summary, while we have made progress in SoTL in HPE, we have not adequately considered context in our SoTL guidance (Glassick, 2000) compared to our general education colleagues (Felten, 2013). This underemphasis on context may result in sparse descriptions of context in the HPE SoTL literature, leading HPE readers to be myopic and failing to see the myriad contextual influences affecting understanding and translation of the described SoTL methods to the reader’s context. If we had richer descriptions of context in the SoTL literature, however, we can then use the ‘context lenses’ to clearly view the surrounding layers that influence education outcomes (Bates & Ellaway, 2016). Finally, with visual clarity, we can then dissect and analyse these layers via mapping them to systems levels using EST (Bronfenbrenner, 1986), so that effective translation and implementation of the described SoTL methods can take place. It is time to correct our myopia by collectively advocating for the rich descriptions of context in our HPE SoTL literature.

Notes on Contributors

Dr Kevin Tan reviewed the literature and developed the manuscript. Dr Foo Yang Yann reviewed the literature and gave critical feedback to the writing of the manuscript. Dr Nigel Choon Kiat Tan reviewed the literature and gave critical feedback to the writing of the manuscript. All authors have read and approved the final manuscript.

Funding

The research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of Interest

Authors have no conflict of interest, including financial, institutional and other relationships that might lead to bias.

References

Bates, J., & Ellaway, R. H. (2016). Mapping the dark matter of context: A conceptual scoping review. Medical Education, 50(8), 807-816. https://doi.org/10.1111/medu.13034

Bronfenbrenner, U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22(6), 723-742. https://doi.org/10.1037/0012-1649.2 2.6.723  

Felten, P. (2013). Principles of Good Practice in SoTL. Teaching & Learning Inquiry: The ISSOTL Journal, 1(1), 121-125. https://doi.org/10.2979/teachlearninqu.1.1.121

Glassick, C. E. (2000). Boyerʼs expanded definitions of scholarship, the standards for assessing scholarship, and the elusiveness of the scholarship of teaching. Academic Medicine, 75(9), 877-880. https://doi.org/10.1097/00001888-200009000-00007

Steinert, Y. (2017). Scholarship in medical education. International Journal of Education and Health, 1(1), 3-4. https://doi.org/10.17267/2594-7907ijhe.v1i1.1657

*Kevin Tan
Office of Neurological Education,
Department of Neurology,
National Neuroscience Institute
11 Jalan Tan Tock Seng,
Singapore 308433
Email: kevin.tan@singhealth.com.sg

Submitted: 27 May 2022
Accepted: 10 June 2022
Published online: 4 October, TAPS 2022, 7(4), 71-72
https://doi.org/10.29060/TAPS.2022-7-4/PV2819

Bhuvan KC^1,2 & P Ravi Shankar³

¹Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia; ²College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia; ³IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia

I. INTRODUCTION

Healthcare systems and medicines operate in a complex landscape and constantly interact with individuals, the environment, and society. In such a complex healthcare delivery system, nonlinearity always exists, and treatments, different healthcare services, and medicines cannot be delivered without factoring in the uncertainty brought about by human, behavioural, system, and societal factors.

A medical doctor prescribes medication/s to treat diseases or healthcare problems following certain treatment protocols and guidelines. However, in the community, several factors affect the adherence and outcomes, such as adverse effects, lifestyle factors, socioeconomic aspects, attitudes, and belief systems, so it is difficult to entirely predict the success of a regimen. These factors that can influence the outcomes of therapy have not received adequate attention. Furthermore, the complexity of healthcare delivery is starker in the treatment of ageing populations or those with chronic diseases.

Our world is becoming increasingly complex. Many uncertainties affect the delivery of healthcare services today. There are inherent challenges within the healthcare system such as lack of adequate funding, ageing population, rising burden of chronic diseases, and overstretched health workforce. In addition, newer challenges such as the impact of climate change on health delivery, the use of digital health technologies, the emergence of new epidemics, and questions regarding sustainability make healthcare delivery complex and uncertain. Healthcare systems operate through a network of subsystems such as hospitals and health systems, clinics, primary healthcare networks, rehabilitation centres, pharmacies, hospices, care homes, families, and patients. They interact with each other in a complex way sometimes producing unintended consequences such as adverse reactions, medication errors, unintended hospitalisations, and hospital-acquired infections. Thus, if we view the health system as a complex entity we can appreciate its dynamic behaviour helping us in delivering health services in a self-organized way (Lipsitz, 2012).

There is an urgent need to teach complexity science to undergraduate and postgraduate health sciences students as it better prepares them to deliver healthcare services and medicines to a dynamic and complex society. The healthcare systems we work for and the communities and societies we deliver healthcare services and medicines are complex. Healthcare delivery is disrupted by access to funding and resources, information and communication technology (ICT) applications, healthcare professionals who keep moving in and out of the system, and the increasing burden of chronic diseases and elderly populations needing several healthcare services and medicines. It is difficult to predict the outcome of the healthcare services and medicines that are delivered via both primary and secondary healthcare systems. Furthermore, it is difficult to predict the impact of healthcare services and medicines on patients. A patient may develop an adverse drug reaction to a medication, patient may have different genetic polymorphisms affecting the metabolism of medication or factors such as socioeconomic conditions, education level, support system might affect the way they receive and use healthcare services and medicines. There has been a growing recognition of such complex needs and the biological, psychological, social, and cultural aspects of medicine in the healthcare sciences curriculum (Quintero, 2014). There is also a greater appreciation for the collaborative care and practice model that brings together medical doctors, pharmacists, nurses, and other healthcare professionals together for patient care (Blount et al., 2006). The collaborative care model attempts to implement change in small and manageable cycles, appreciating the complexity involved. We must introduce complexity in medicine and pharmacy teaching and learning by introducing concepts, terminology, and lexicons regarding complexity and uncertainty. Students’ engagement and appreciation of the complexity of healthcare systems and delivery can be assessed through reflective practice, clinical reasoning, and evidence-based practice.

Complexity recognises that relationships may be nonlinear and emphasises the relations and interconnections between different components. Flow, interdependence and the emergence of structures and patterns are emphasised. An acceptance of the non-linear cause and effect relationship is stressed. Evidence-based medicine is based on statistics derived from large populations. Applying the results to an individual patient requires caution. Diagnosis and treatment outcomes are probabilistically determined. With the advent of large data sets the probabilistic nature of medicine is becoming apparent. A particular set of signs and symptoms provides a set of differential diagnosis in either increasing or decreasing order of probability. A variety of social, emotional, and political factors can influence treatment decisions, access to care, and treatment outcomes.

Universities have begun to realise the importance of teaching complexity science to medicine and health sciences students. A study by Jorm et al. (2016) had shown how complexity theory can be used to guide interprofessional learning. It showed how complexity theory can be used to design cases, formats, and assessments and how it enabled students to achieve complex interprofessional learning outcomes (Jorm et al., 2016). Another study by Jorm and Roberts (2018) reported the use of complexity theory to design evaluations with a new focus on developing medical students as future change agents for the transformation of the health system and patients’ lives (Jorm & Roberts, 2018). Several institutions like the Santa Fe Institute (New Mexico, United States) have already begun training programs on complexity in medicine and health care systems. Such programs and training need to be developed and evaluated globally so that medicine and pharmacy students can better tackle the complexity of health systems and the uncertainty around delivering medicines and healthcare in a complex environment. Training students for complexity today can ensure they are better prepared for both current and future challenges. 

Notes on Contributors

BKC contributed to the conceptualisation of the manuscript, wrote the first draft, revised the subsequent draft, and contributed to the final draft. PRS contributed to the conceptualisation of the manuscript and critically revised the first draft. The author contributed to the subsequent revision and finalisation of the manuscript.

Funding

No funding has been received for this article.

Declaration of Interest

The authors state that they do not have any conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.

References

Blount, A., DeGirolamo, S., & Mariani, K. (2006). Training the collaborative care practitioners of the future. Families, Systems, & Health, 24(1), 111-119. https://doi.org/10.1037/1091-7527.24.1.111

Jorm, C., Nisbet, G., Roberts, C., Gordon, C., Gentilcore, S., & Chen, T. F. (2016). Using complexity theory to develop a student-directed interprofessional learning activity for 1220 healthcare students. BMC Medical Education, 16(1), Article 199.  https://doi.org/10.1186/s12909-016-0717-y

Jorm, C., & Roberts, C. (2018). Using complexity theory to guide medical school evaluations. Academic Medicine, 93(3), 399-405. https://doi.org/10.1097/ACM.0000000000001828

Lipsitz, L. A. (2012). Understanding health care as a complex system: The foundation for unintended consequences. JAMA, 308(3), 243-244. https://doi.org/10.1001/jama.2012.7551

Quintero, G. A. (2014). Medical education and the healthcare system-why does the curriculum need to be reformed? BMC Medicine, 12(1), Article 213. https://doi.org/10.1186/s12916-014-0213-3

*P Ravi Shankar
IMU Centre for Education
International Medical University+94711698916
126, Jln Jalil Perkasa 19, Bukit Jalil,
57000 Kuala Lumpur, Malaysia
Email: ravi.dr.shankar@gmail.co

Submitted: 24 December 2021
Accepted: 23 March 2022
Published online: 5 July, TAPS 2022, 7(3), 60-62
https://doi.org/10.29060/TAPS.2022-7-3/PV2727

Ikuo Shimizu¹, Shuh Shing Lee², Ardi Findyartini³, Kiyoshi Shikino⁴, Yoshikazu Asada⁵ & Hiroshi Nishigori⁶

¹Center for Medical Education and Clinical Training, Shinshu University Hospital, Matsumoto, Japan; ²Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Medical Education & Medical Education Center-Indonesia Medical Education & Research Institute, Faculty of Medicine Universitas Indonesia; ⁴Department of General Medicine, Chiba University Hospital, Chiba, Japan; ⁵Center for Information, Jichi Medical University, Shimotsuke, Japan; ⁶Center for Medical Education, Nagoya University, Nagoya, Japan

I. INTRODUCTION

After the “To err is human” report in 1999, health care systems have become aware of the serious consequences of failures in health care and have sought to reduce them by enhancing patient safety education. The current medical educators consider that errors are inevitable in clinical practice and think of learning from these errors to improve the quality of the practice and maintain the safety of health care services. This effort on quality improvement and patient safety is now regarded as part of patient safety education. One example is the Morbidity and Mortality conference, a continuous professional development opportunity that had sprung from the efforts of learners to improve practice through the examination of medical errors and unfavourable outcomes. Openness to discussion and study of errors, with a realisation that “errors must not be accepted as a person’s fault”, is central to their message.

To err is human, as is the educators. Educators plan and implement various educational practices, but they sometimes fail to achieve the expected outcomes. We educators sometimes find that our educational practices fail to deliver the intended results or have unexpected adverse outcomes, and we consider such outcomes to be failures. Therefore, it is crucial for faculty to acknowledge the failure and try to make further improvements. In addition to educators’ reflections, they are involved in an institutional opportunity to reflect on practices as a form of faculty development. Faculty development includes initiatives designed to improve the performance of faculty members in teaching, research and administration. However, failures in educational practices are often difficult to be recognised and disclosed to colleagues and learners. Admitting and revealing failure is often difficult for clinicians, and it is no different for educational practitioners. Such educators can be called “problem” educators, just as learners who have difficulty improving their competence appropriately can be called “problem” learners. (Steinert, 2013). Thus, there is a scarce opportunity for educators to recognise and share their failed experiences. Such an attitude of neglect will have a negative impact not only on the quality of educational practices but also on the student-faculty relationship in the long run. It is nothing but a tragedy in medical education to allow faculty to become “problem” educators.

Therefore, the present article states theoretical background to understand how to learn from failure, especially the obstacles for educators, and propose a framework for taking hints from the recent patient safety education.

II. WHY TRADITIONAL SAFETY PARADIGM DOES NOT WORK FOR REFLECTION

Reflecting on experience is crucial for all educators because it enhances learning from practice. When they reflect on unsuccessful educational practices, educators recognise and analyse what they actually did, what happened during or after their practices, and how to improve their practices in the future.

However, learning through self-reflection requires learning strategies, motivation, and awareness of failure (metacognition). While faculty development can provide the strategies, it becomes an environment without motivation and awareness of failure if it lacks psychological safety. Motivation is required for connecting learning with real-life experiences. Educators can facilitate effective self-regulation by thinking critically about their practice and providing attributional reflection (Ryan & Deci, 2000). In particular, extrinsic motivation does not lead to self-reflection; intrinsic motivation is a necessary condition. Even though faculty development provides extrinsic opportunities, it is difficult for “problem” educators without intrinsic motivation to sufficiently reflect on their failures.

Also, there are concerns about whether the psychological safety of educators is ensured when they are asked to improve their educational practices. Firstly, it is burdensome for participants to accept negative results about their practices. If such an evaluation process does not ensure psychological safety, required for self-directed learning (Edmondson, 2014), it will be difficult for the participants to improve their practices. Psychological evidence also shows that people who have fewer teaching competencies tend to overestimate their skills, which might be another risk to hinder the attitude to reflect educational practices. Secondly, a concern about psychological safety lies that some “problem” educators are not even aware of their failures.  This phenomenon does not happen in “problem” learners, especially in undergraduate education. While learners often realise they have a problem through some form of summative assessment, educators need to engage in reflection themselves. However, an environment with psychological safety can promote proactive behaviours like self-reflection (Lin, 2007).

 

III. USE OF SAFETY-II PARADIGM FOR EDUCATORS” PSYCHOLOGICAL SAFETY

In order to overcome these obstacles against the suitable faculty development environment to learn from the failed educational practices, the authors consider psychological safety and suggest shifting our perspective of failure by drawing on the quality improvement strategies. Defining an ideal practice as successful and others that are not (i.e. failures) is derived from the traditional safety management paradigm called Safety-I (Hollnagel, 2014). In contrast to the traditional paradigm, the use of the new paradigm has recently been proposed and become prominent. This paradigm (Safety-II) presupposes that there will always be a gap between the results intended by the practitioners and the actual results. Deviation from the plan itself is not considered a failure. Instead, we can consider such gaps as adaptations and analyse why they occurred and how they worked. The analysis will bring about continuous improvement in a more constructive way.

Safety-II paradigm can provide educators with a new insight that an unexpected result of educational practices can be recognised as a more neutral form rather than “failure”. This perspective would help ensure psychological safety and make it easier to bring about self-directed learning. Also, this paradigm can provide a new perspective on implementing educational theories or methods in the context of health professions education. Educators should always pay attention to gaps between what we anticipate and what actually happens; it is essential to establish a causal relationship by reflecting on such gaps.

We keep two things in mind for reflecting on the practices according to the Safety-II paradigm. First, we should describe the outcome of the practice objectively as an actual result rather than a failure. This perspective brings to faculty development the results of education that did not work (i.e., failures) and the unexpectedly good accomplishments. As a result, it will help focus on the original outcome of education and promote self-reflection. Second, the results should be contrasted with expected results at a glance. Then we can discuss the causes lying between expected results and actual results and what to be improved. Adjustments are made to achieve the desired outcome under expected and unexpected conditions. Safety-II approach might significantly contribute to the evaluation of the practice, by considering unexpected outcomes rather than only failures. Therefore, analysing educational programs from a Safety-II-based perspective will make it easier to find the adjustments that were actually made and enable educators to perform resiliently. It would be not easy to achieve by simply pointing out deviations from ideal practice based on Safety-I. This perspective will allow educators to become more aware of resilience in their educational practices. Furthermore, as educators discover the gaps between planned and actual results from Safety-II, they will be motivated to compare them, thus leading to a critical analysis and continuous improvement of their educational practices.  

IV. CONCLUSION

The Safety-II paradigm has the potential to move us away from simply judging failed practices, analysing them from a more constructive perspective, and helping us acquire pragmatic improvements. Then it can help both learners and educators better cope with the complexity of medical education. Furthermore, we can expect to obtain the same outcome as the continuous improvement process; we believe this suggestion will help make our reflection valid and inspire us to professional development. Therefore, it would be further highlighted as a seed for future analytical strategies because it has potential value in the field.

Notes on Contributors

Ikuo Shimizu reviewed literature and took the lead in writing and editing the manuscript.

Shuh Shing Lee contributed to the theoretical ideas for this manuscript.

Ardi Findyartini contributed to the theoretical ideas for this manuscript.

Kiyoshi Shikino contributed to the concept and aided the development of the manuscript.

Yoshikazu Asada contributed to the concept and aided the development of the manuscript.

Hiroshi Nishigori advised and provided feedback on the manuscript, aided the development of the manuscript.

All authors discussed and contributed to the final manuscript.

Acknowledgement

The authors wish to thank Professor Takuya Saiki at Medical Education Development Center, Gifu University, Japan, for providing us with an opportunity to conduct a workshop regarding the Safety-II-based approach on May 24, 2020.

We would also like to appreciate Editage (www.editage.com) for English language editing.

Funding

This work was supported by JSPS KAKENHI under Grant #21H03161. This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

Declaration of Interest

The authors have no conflict of interest to declare.

References

Edmondson, A. C. (2014). The competitive imperative of learning. IEEE Engineering Management Review, 42(3), 110-118. https://doi.org/10.1109/emr.2014.6966928

Hollnagel, E. (2014). Safety-I and safety-II: The past and future of safety management. Ashgate. https://doi.org/10.1201/9781315607511

Lin, H. F. (2007). Effects of extrinsic and intrinsic motivation on employee knowledge sharing intentions. Journal of Information Science, 33(2), 135-149. https://doi.org/10.1177/0165551506068174

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68

Steinert, Y. (2013). The “problem” learner: Whose problem is it? AMEE Guide No. 76. Medical Teacher, 35(4), e1035–e1045. https://doi.org/10.3109/0142159X.2013.774082

*Ikuo Shimizu
Center for Medical Education and Clinical Training,
Shinshu University Hospital,
3-1-1 Asahi, Matsumoto,
Nagano, 390-8621, Japan
Email: ishimizu@shinshu-u.ac.jp

Submitted: 1 February 2022
Accepted: 16 February 2022
Published online: 5 July, TAPS 2022, 7(3), 57-59
https://doi.org/10.29060/TAPS.2022-7-3/PV2737

Garry Soloan^1,2 & Muhammad Athallah Arsyaf^1,2

¹Medical Education Center, Indonesian Medical Education & Research Institute (IMERI) Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; ²Undergraduate Program in Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

From exams based on short answer questions and multiple-choice questions with a definite answer keys, to project-based, independent, and problem-oriented studies offered in university, the rapid dive transitioning from pedagogical learning into the world of andragogy within the university, truly is one of the highlights of a scholar’s long journey. A 6 year-long habit of having information spoon-fed into our mind, meticulously studying every Cambridge GCE A-Levels past marking scheme and question papers available on the internet had led me to believe that there always had to be the correct, if not perfect, way of finishing an assignment.

Feeling assured and confident on how to approach my study in medicine, it was a surprise to discover that the medical school landscape was far different than what I was used to. Yet being able to define “perfect” in medical school assignments, I found myself approaching every essay as if it was a work of art. Hours, days would be spent writing, reading, and re-writing a single essay assignment. I laboured through every paragraph, often spending more than 30 minutes to finish a paragraph. I regularly consulted a thesaurus, ensuring no word had been repeated within a paragraph, always searching for the perfect word to convey my thoughts. Opinions of others were sought multiple times: Should I mention this? Should I use this word?

The brand-new learning method through problem-based discussions were exciting, yet no less frustrating at times. In completing our assignments for each discussion session, it is likely that we would encounter numerous journals that, more often than not, are contradictory to each other. Significant time would be spent creating a comprehensive literature review, crafting an interactive and thorough presentation, yet at the end of the week, more often than not I doubt that I would be able to answer the simple question of, “what would be the most appropriate treatment for the patient within the trigger case?”.

Over time, I would come to the realisation that such habits and behaviour would not be sustainable in the long run, as I continue to ponder to find the “right way” to study in medical school. By the time that this article was written, 24 months had passed, and although I had an overall satisfactory GPA, each discussion sessions, essay assignment remained invariably the same: challenging as ever. Reflecting back on my prior habit in learning, it is most likely clear to imply that my actions were a result of some degree of perfectionism. The new medical education landscape has caused a turbulence in these habits but as of now, it is still something I am pushing to adapt to by using that drive as something good. But this perfectionist manner of thinking is known to affect more medical students than ever reported, and the perfectionism comes in various degrees in an unpredictable pattern. It might be argued that perfectionism is not necessarily a good trait to have in the study of medicine, but entertaining this idea is not as easy as black and white.

Perfectionism could be simply described as high personal standards with very specific and non-flexible goals to meet. The reactions to these high standards are explained in two different concepts: adaptive and maladaptive perfectionism. The difference between both concepts lies on a thin line, where adaptive perfectionism refers to the standard one puts on his or her performance as a driving force to reach a certain goal. This type of perfectionism, although highly pushing of themselves, still sets realistic standards and is only related to their strivings. Most importantly, the failure of achieving certain goals does not result in self-deprecation. On the other hand, maladaptive perfectionism refers to the same concept of having high standards, but often intensely self-critical over small failures, constantly concerned about creating mistakes, and undermining their success attributing to their low self-esteem. It is simply the overwhelming concern of wanting to do the best, creating a barrier in enjoying a happy life and compromises their state of mind. This type of perfectionism is the most often associated with mental disorders such as anxiety or depression, which sadly, is commonly found among medical students (Seeliger & Harendza, 2017).

Among practicing physicians, the concept of perfectionism often lies in a grey area. In their daily practice, having high standards for their care without having unrealistic expectations is sometimes difficult to do, since responsibilities of physicians are put on the highest pedestals to begin with. As mentioned earlier, adaptive perfectionism presents itself as something good, simply an ambition to always do better without fear of failure. The learning process in medical school is shaped in such a way as an effort to promote this type of perfectionism. As mentioned in a review on medical education by Mylopoulos et al. (2018), most of its studies consist of direct assessments of student’s abilities in recalling factual information. These performance-focused assessments support perfectionism in the lives of students, since their performance is clearly measured by numbers, which for a perfectionist is a perfect judgment of their standards. The review continues by emphasizing on what should be the important components of medical education, including understanding rather than remembering, allowing for challenges and failure to occur as a lesson learned experience, and supporting the variation in individual approaches that come with the aforementioned challenges & failure (Mylopoulos et al., 2018).

So, where do perfectionism stand in these ideal medical education standards in students? Medical education is slowly but steadily pushing towards allowing medical students to dive deep first-hand into their studies and approach it individually, letting mistakes and personal insights influence their clinical judgement before giving the appropriate feedback to put them back on the right track had they stray too far. This type of learning creates opportunities for students to create errors, those of which are hoped to be able to be transformed into valuable learning opportunities. For those with adaptive perfectionism, it could be assumed that they simply adapt to the situation and strive to do well in this new environment as their goals are to strive for good quality outcomes. This assumption is easy to make since adaptive perfectionism rarely associates with the concern of messing-up. However, those with maladaptive perfectionism would most likely succumb under the pressure of starting a learning experience on their own and not having standards to do it perfectly. This is because their actions are fully based on their concerns and feelings, allowing the trait of. Maladaptive perfectionism to become a mediator for mental health disorders as well as an overall decline in quality of life.  (Rutter-Eley et al., 2020) The feeling of not knowing what to expect is often the significant cause of anxiety in students with maladaptive perfectionism, and it could lead to further mental instabilities if their performances turn out to not be up to their standards (Bußenius & Harendza, 2019).

From these, there is an implication that if medical education continues to push forward the realization of a new, significantly independent approach in teaching and learning, those with maladaptive perfectionism would simply not survive. This argument could support another issue relating to medical school admission, where several studies had recommended means and the possible benefits in establishing maladaptive perfectionism as a trait to be selected out during medical school selection process (Gärtner et al., 2020; Seeliger & Harendza, 2017). Unfortunately, adaptive and maladaptive perfectionism sometimes live alongside one another, causing a combined effect that is somewhat unpredictable. Because of this, the authors believe that perfectionism could not be ruled out as a negative trait since mental concerns may come and go along the way, where one could use their perfectionism as a driving force one day and use it against them in an episode of low self-esteem another day. Marking it as an elimination characteristic in medical education would not be fair for those with a more stable perfectionism, since we will never know for sure which perfectionist is overly driven, or overly concerned.

It is true that maladaptive perfectionism could pose serious challenges in the learning process of a medical student. This is why traits like these, along with other personality traits that disrupt a good learning environment for an individual, calls for adequate support from the medical school. The trait of maladaptive perfectionism runs rampant among medical students, and it could be tackled by reassurance from their community, teachers, and friends, as well as creating a learning environment that limits the existence of fear-based achievements. (Mylopoulos et al., 2018) The thin line between maladaptive and adaptive perfectionism makes it possible to shape those with the more negative trait into a more positive trait. All in all, we believe that perfectionism is not a trait to shun from medical education, but it is one which medical schools should be able to recognise and provide adequate support in order to nourish the said maladaptive perfectionism, into an adaptive perfectionism in order to nurture physician who would be able to consistently set the bar high, without compromising their own well-being.

Notes on Contributors

Both authors are third year medical students from the Faculty of Medicine, Universitas Indonesia, who is currently undergoing a research internship at Medical Education Center, Indonesia Medical Education & Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia.

Garry Soloan designed and led the study, contributed to argument development, conceptual development, and develop & finalise the manuscript. Muhammad Athallah Arsyaf contributed to argument development, conceptual development, and manuscript development.

Acknowledgement

This paper is written during the author’s internship program at the Medical Education Center, Indonesian Medical Education & Research Institute (IMERI) Faculty of Medicine, Universitas Indonesia. We would like to thank Ardi Findyartini, MD, PhD and Nadia Greviana, DDS, MMedEd, our mentors from Medical Education Center, Indonesia Medical Education & Research Institute (IMERI) FMUI who have provided advice, feedback & mentorship during the writing of this paper.

Declaration of Interest

The authors declare no competing interests.

Funding

No funding is provided for this personal view article.

References

Bußenius, L., & Harendza, S. (2019). The relationship between perfectionism and symptoms of depression in medical school applicants. BMC Medical Education, 19(1), 1-8. https://doi.org/10.1186/s12909-019-1823-4

Gärtner, J., Bußenius, L., Prediger, S., Vogel, D., & Harendza, S. (2020). Need for cognitive closure, tolerance for ambiguity, and perfectionism in medical school applicants. BMC Medical Education, 20(1), 1-8.

Mylopoulos, M., Kulasegaram, K., & Woods, N. N. (2018). Developing the experts we need: Fostering adaptive expertise through education. Journal of Evaluation in Clinical Practice, 24(3), 674-677. https://doi.org/10.1111/jep.12905

Rutter-Eley, E. L., James, M. K., & Jenkins, P. E. (2020). Eating disorders, perfectionism, and quality of life: Maladaptive perfectionism as a mediator between symptoms of disordered eating and quality of life. The Journal of Nervous and Mental Disease, 208(10), 771-776.

Seeliger, H., & Harendza, S. (2017). Is perfect good? – Dimensions of perfectionism in newly admitted medical students. BMC Medical Education, 17(1), 1-7. https://doi.org/10.1186/s12909-017-1034-9

*Garry Soloan
Jl. Salemba Raya No.6, RW.5,
Kenari, Kec. Senen
Kota Jakarta Pusat
Daerah Khusus Ibukota
Jakarta 10430
Tel: +628121162323
Email: garry.soloan@hotmail.com

Submitted: 28 May 2021
Accepted: 25 August 2021
Published online: 4 January, TAPS 2022, 7(1), 112-114
https://doi.org/10.29060/TAPS.2022-7-1/PV2544

Sok Ying Liaw & Siew Tiang Lau

Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. BACKGROUND

The coronavirus disease 2019 (COVID-19) has been declared as a pandemic. On 7 February 2020, the Ministry of Health (MOH), announced the suspension of all clinical postings. All healthcare students were ordered to withdraw from hospitals within hours after the announcement. Graduating year nursing students from the National University of Singapore (NUS) were into their final phases of clinical postings. The suspension of clinical postings greatly disrupted the students’ preparations in developing clinical competencies critical to their future nursing professions.

Across the world, healthcare policymakers and institutions have responded to nursing students’ clinical education in a variety of ways. One compelling argument for continuing the clinical education of graduating nursing students is to treat them as part of the healthcare teams and leverage their clinical skills to boost the capacity of care teams. However, as our nursing students were at an earlier stage of their final year clinical practicum and have yet to acquire the knowledge, skills and clinical experience of a qualified nurse, it may be argued that their involvement in patient care delivery would have primarily been for educational purposes. Thus, the potential of compromising patient safety due to lack of supervision by the overwhelmed trained staff, the risks of contracting the contagion and giving rise to psychological concerns might not overweigh their educational benefits.

In Singapore, healthcare policymakers and institutions face the challenge of balancing education, healthcare service and potential risks for students in the healthcare settings. The main reasons for the suspension of clinical postings were the unknown risk of COVID-19 at that timepoint and the need for hospitals to manage their resources to transform their facilities and manpower to care for infectious patients. The suspension of clinical postings affected the nursing students’ abilities to fulfil the required number of clinical hours set out by the Singapore Nursing Board (SNB) to be registered as a registered nurse. Academic nurses at the NUS had to react quickly by employing simulation strategies to replace clinical hours. This gave rise to a debate around evidence-based practice versus practicalities in designing simulation as a substitute for clinical practice in nursing clinical education. 

II. SIMULATION TO REPLACE CLINICAL PRACTICE HOURS

In light of the suspension of clinical placements, the SNB has permitted the substitution of 160 out of 400 clinical hours (40%) of the final year students’ clinical practicums with simulation. This can be supported by existing evidences on the use of simulation as a substitute for clinical placement in prelicensure nursing programmes (Curl et al., 2016). In our plan to replace 160 clinical hours, we initially assumed a ratio of one hour of simulation to one hour of clinical time. However, we recognised the challenges to implement this 1:1 ratio for the training of 300 nursing students using the existing simulation facilities, along with the need to adhere to the safe distancing measures initiated by the university. We had to plan a class size of not more than ten persons in a simulation laboratory, including a facilitator and a simulated patient, in order to keep everyone at a safe distance of at least two metres apart. Given these resource implications, we equated a ratio of one hour of simulation to two hours of clinical practice.

There is no clear evidence on the substitution ratio for simulation hours to clinical placement hours. A study by Curl et al., (2016) evaluated the use of simulation experiences to replace 50% of clinical experiences by employing a ratio of a substitute of one hour of simulation to two hours of clinical experience. Bogossian et al. (2019) postulated that as a simulation can be both controlled and time-compressed, it should draw more than parity in clinical practice hours, which is an aspect worth future investigation.

III. TYPES OF SIMULATION MODALITIES

We had to work out different types of simulation modalities to meet the 80 hours of simulation learning as well as to achieve the learning outcomes based on the SNB’s competency domains for registered nurses. The 80 hours also included the simulation-based assessment on clinical performance and post simulation activities on reflective writing to provide evidence to SNB on the achievement of learning outcomes. Earlier studies focused mainly on the use of high-fidelity simulations to replace clinical practices (Bogossian et al., 2019; Curl et al., 2016). The adequacy of existing simulation facilities and their accesses were constraints that led us to explore a variety of simulation modalities, including simulated clinical immersion using high-fidelity simulations, procedural simulations and computer-based simulations.

We adopted and expanded our earlier developed evidence-based simulation program, known as SIMulated Professional Learning Environment (SIMPLE) to create simulated clinical immersion learning and assessments in the NUS Centre for Healthcare Simulation. The availability of the SIMPLE guide, which included learning objectives, details of scenarios, debriefing guides and scripts for simulated patient, prompted our quick planning and implementation of the facilitators’ briefing and simulation learning. A total of six simulation sessions were implemented based on themes related to common ward nursing practices. In each simulation session, we incorporated two patients (one high-fidelity simulator and one simulated patient) in a simulated general ward setting. Our earlier study provided evidence on the benefits of the SIMPLE programme in promoting nursing students’ transition-to-practice experiences (Liaw et al., 2015). We also put in place a contingency plan on the use of video-based simulations in case we could not conduct face-to-face simulations. The video-based simulations were conducted via video conferencing for a small group of students who were unable to attend face-to-face simulations.

In the simulated clinical immersion scenarios, the students were required to perform a set of clinical procedures related to patient care. Thus, we incorporated procedural simulations to provide opportunities for the students to revise the procedures and practise the technical skills that they had acquired in years one and two. As a result of a lack of simulation facilities and faculty resources, the self-direct practice approach was adopted for procedure simulation learning. The students were given case scenarios and a set of requisites, including a wound dressing set, an intravenous priming set and an indwelling catheterization set, to practise the clinical procedures innovatively at home. They were also instructed to develop and submit video recordings of their best ten performed procedures, selected from a list of core skills for registered nurses, to provide evidence of their time (e.g. 20 hours) in engaging self-directed learning as well as for instructor feedback. Apart from procedural simulation learning, we managed to implement procedural simulation assessments on donning and doffing personal protection equipment (PPE) at remote locations by leveraging telecommunication resources using Zoom’s video conference calls. This approach enabled direct observations of performance and feedback between a student and an assessor.

Earlier, we developed two computer-based simulations, e-RAPIDS (Rescuing A Patient In Deteriorating Situation) and CREATIVE (Create Real-time Experience And Teamwork In Virtual Environment), to allow the students to participate in experiential learning. These were considered valuable resources for students’ off-site learning for the development of non-technical skills. Using experiential learning approach, the e-RAPIDS provided a self-directed learning resource for students to develop clinical reasoning skills through the application of knowledge to problem solve deteriorating virtual patients with feedback from multiple scenarios. The CREATIVE provided nursing students opportunities to undertake simulation-based interprofessional education with medical students on nurse-doctor communication skills training. We evaluated the effectiveness of these computer-based screen simulations on students’ learning outcomes performance by comparing with high-fidelity simulation in the previous studies (Liaw et al., 2014, 2020). The non-inferiority outcomes of these simulations to high-fidelity simulations may justify the use of these computer-based screen simulations to replace some clinical hours.

IV. CONCLUSION

The COVID-19 outbreak posed a unique challenge to nursing clinical education.  The cessation of clinical placements led to immediate concerns on nursing students’ clinical competencies, which necessitated the adoption of various simulation resources as an alternative means of delivering clinical education. The inadequacy of existing simulation resources and their limited accessibilities posed challenges in the replacement of clinical hours. Nonetheless, this COVID-19 pandemic has prompted us to embrace more innovative simulation initiatives, including video-based simulations and tele-simulations. These innovations inevitably gave rise to a debate around evidence-based practice versus practicalities for designing simulation as a replacement for nursing clinical practice. More evidence is warranted to justify the use of different types of simulation modalities to replace clinical practices in terms of learning outcomes and cost-effectiveness. Such evidence can inform future implementations and policy development on the regulation of using simulations to replace clinical practices to ensure student competency for the nursing workforce. We look forward to seeing more simulation innovations along with evaluation research for simulation technology amid the COVID-19 pandemic.

Notes on Contributors

Sok Ying Liaw designed and implemented the simulation and took the lead in writing the manuscript.

Siew Tiang Lau contributed to the planning of the simulation and aided the development of the manuscript.

Acknowledgement

The authors would like to thank the faculty staff of Alice Lee Centre for Nursing Studies for supporting the implementation of simulation. The authors would like to thank the National University Health System, Research Support Unit, for providing editing services to this manuscript.

Funding

The authors have no funding to report.

Declaration of Interest

The authors have no conflict of interests to declare.

References

Bogossian, F. E., Cant, R. P., Ballard, E. L., Cooper, S. J., Levett-Jones, T. L., McKenna, L. G., Ng, L. C., & Seaton, P. C. (2019). Locating “gold standard” evidence for simulation as a substitute for clinical practice in prelicensure health professional education: A systematic review. Journal of Clinical Nursing, 28(21-22), 3759-3775. https://doi.org/10.1111/jocn.14965

Curl, E. D., Smith, S., Chisholm, L. A., McGee, L. A., & Das, K. (2016). Effectiveness of integrated simulation and clinical experiences compared to traditional clinical experiences for nursing. Nursing Education Perspectives, 37(2), 72-77. https://doi.org/10.5480/15-1647

Liaw, S. Y., Chan, S. W.-C., Chen, F.-G., Hooi, S. C., & Siau, C. (2014). Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: Randomized controlled trial. Journal of Medical Internet Research, 16(9), e214. https://doi.org/10.2196/jmir.3322

Liaw, S. Y., Ooi, S. W., Rusli, K. D. B., Lau, T. C., Tam, W. W. S., & Chua, W. L. (2020). Nurse-physician communication team training in virtual reality versus live simulations: Randomized controlled trial on team communication and teamwork attitudes. Journal of Medical Internet Research, 22(4), e17279. https://doi.org/10.2196/17279

Liaw, S. Y., Palham, S., Chan, S. W.-C., Wong, L. F., & Lim, F. P. (2015). Using simulation learning through academic-practice partnership to promote transition to clinical practice: A qualitative evaluation. Journal of Advanced Nursing, 71(5), 1044-1054. https://doi.org/10.1111/jan.12585

*Sok Ying Liaw
Alice Lee Centre for Nursing Studies,
Yong Loo Lin School of Medicine,
National University of Singapore
Level 2, Clinical Research Centre, Block MD11
Singapore 117597
Email: nurliaw@nus.edu.sg

Submitted: 8 June 2021
Accepted: 11 August 2021
Published online: 4 January, TAPS 2022, 7(1), 109-111
https://doi.org/10.29060/TAPS.2022-7-1/PV2558

Jimmie Leppink

Hospital virtual Valdecilla, Spain

I. INTRODUCTION

Single case designs (SCDs) comprise repeated measurements (time series) of the same variables of interest (Van de Schoot & Miocevic, 2020) to understand changes in knowledge, skill, attitude or other constructs in a defined time period that includes one or more events or developments that may affect that change. Possible units of analysis include individuals (e.g., individual skill development), teams (e.g., team dynamics), or settings (e.g., situational-contextual change). Whether the outcome variables are quantitative (e.g., time-on-task), qualitative (e.g., changes in habits or preferences), or some combination of the two (e.g., test scores and transitions in practice strategy), a range of parametric and nonparametric statistical models are available for analysis at the level of N = 1, and the outcomes of multiple N = 1 analyses can be combined using multilevel and meta-analytic models (for reviews and examples, see: Leppink, 2020; Van de Schoot & Miocevic, 2020). This makes SCDs useful for any sample size and, contrary to traditional randomised controlled experiments and other group comparison studies, can help health professions education (HPE) researchers and practitioners to (1) Respect the dynamic nature of learning, (2) Use no more resources than needed, (3) Bridge the research-practice gap, and (4) Appreciate diversity and approach challenges in the sector accordingly. Each of these advantages is explained in the following.

II. RESPECT THE DYNAMIC NATURE OF LEARNING

Although learning by definition involves time, the vast majority of traditional randomised controlled experiments and other group comparison studies focus on performance at a single occasion or at best at two occasions. SCDs can incorporate quantitative and qualitative information to understand the longitudinal and non-linear nature of learning, effects of interventions or events, and possibly the temporal order of changes. For example, in a five-year medicine program in which we assess knowledge, skill and attitude every 3-4 months in each year of the program, we can monitor change in each of these variables and study possible temporal orders in changes at the level of the individual student as well as – through multilevel and meta-analytic models that combine individual outcomes – at the level of a larger group (e.g., changes in attitude tending to precede changes in knowledge, or the other way around). Although a commonly perceived limitation of SCDs is a lack of generalisability to larger populations, generalisability is not always of interest in our field (e.g., ‘what is the level of competence of this resident at this point?’, or ‘does this simulation session contribute to more effective communication in this team in this hospital?’), and where it is of interest (e.g., under which conditions can the use of virtual reality games help to improve communication skills?), it can be increased through replication studies from different settings the findings of which are combined in multilevel and meta-analytic models.

III. USE NO MORE RESOURCES THAN NEEDED

While traditional randomised controlled experiments and other group comparison studies with a limited number of measurements (usually one or two) often require more than 100 participants, SCDs – through their use of series of repeated measurements – allow researchers and practitioners to investigate educationally interesting phenomena with any number of individuals, teams or situations including one (i.e., N = 1). This is great for example for institutions that do not have large numbers of students or residents (e.g., eleven students or six residents) and do not pretend that the outcomes of their study can be generalised to all of the rest of the world, and is one of the reasons why in some clinical areas (Van de Schoot & Miocevic, 2020) and some areas in education (Leppink, 2020) SCDs have already been used successfully for a while. In addition, not using more resources than needed is always important and even more so in times of enormous pressure on healthcare systems across the world. To use an example from assessment practice, decisions about the progression of individuals or teams usually require longer exams when performance is borderline (i.e., almost at the expected level with minor lapses that would not cause concerns for patient outcomes) compared to where performance is good or poor. In this context, SCDs can help us determine when we have sufficient information about the knowledge (how many questions?), techniques (how many tasks?), skills (how many stations?) or attitudes (how many portfolio reflections?) of a specific individual or team being assessed in order to make informed and confident decisions.

IV. BRIDGE THE RESEARCH-PRACTICE GAP

Most group comparison studies include the unethical and often practically nonsensical action of withholding an educational intervention from some participants (control group), whereas in SCDs the question is not if but when that intervention takes place. Just like in a study on skydiving one would never include a ‘control’ condition in which participants are not allowed to open their parachute (the question should be when not if one should open that parachute), in an educational context in which the use of for instance virtual reality technology which allows students or residents to practice with complex anatomy structures in 3D is an inherent part of an anatomy training programme, including a condition in which no virtual reality technology is offered does not make sense. A more appropriate question in this context is when to use the virtual reality technology. On a related note, in complex domains such as medicine, we tend to move from simple to complex because more complex tasks require one to be able to complete a series of simpler tasks. Sticking with simple tasks only or moving from complex to simple does not make sense in this practice, and it is therefore pointless to design experiments which incorporate such conditions (i.e., a no-complex-tasks control group or a group in which we start with complex and end with simple). SCDs which introduce (more) complexity at different points in time for different participants or teams make more sense, and if that starting point is randomised for different participants, we speak of a single case experimental design (SCED; Van de Schoot & Miocevic, 2020); experimental because like in traditional experiments we have both manipulation (here: simple vs. more complex) and randomisation. SCEDs can facilitate causal inference, although where effects of several interventions are considered the complexity of the design as well as the number (generally a higher demand) and timing of measurements (sufficient measurements in each of several stages of the study) will require very careful thought. Finally, HPE is ultimately about contributing to the best possible healthcare, hence research questions on possible effects of training on future healthcare performance (e.g., are we delivering good doctors?) are key (Nickson et al., 2021; Prideaux, 2019), and the longitudinal character of SCDs allows us to study these questions.

V. APPRECIATE DIVERSITY AND ACT ACCORDINGLY

As eloquently formulated by Prideaux (2019), medical schools must “direct their activities to local priorities and to serving local health systems” (p. 25) and at the same time healthcare systems across the world share many challenges and can all benefit from solid theory on what works in which circumstances. SCD (or in experimental form called SCED) findings from different institutions or settings can be combined into meta-analyses (Van de Schoot & Miocevic, 2020) and systematic reviews, helping us to understand commonalities and diversity across institutions, to develop existing and new theory, and to approach sector challenges accordingly. Although where generalisability is of interest smaller samples tend to provide substantially less information than larger samples, many carefully performed smaller sample studies combined in meta-analyses and systematic reviews can make a more powerful and, in our field, much more useful end result than small numbers of larger sample studies. Besides, although the number of measurements needed depends on what we are measuring and not all models require large numbers of measurements (e.g., 10 measurements of the same individual for relatively simple conclusions about that individual), larger numbers of measurements – where that it is possible and makes sense in the context at hand – generally provide more information and allow for a study of more complex relations than smaller numbers of measurements.

VI. CONCLUSION

Nearly 17 years ago, Johnson and Onwuegbuzie (2004) published their immensely popular article “Mixed methods research: A research paradigm whose time has come”. SCDs allow researchers to adopt that mixed methods lens by integrating qualitative and quantitative information on complex phenomena such as learning and other types of development, to address the needs of educational and healthcare practice while using no more resources than what is needed (no more statistical power calculations for group experiments of more than 100 participants that include conditions that would never occur in educational practice), and to appreciate diversity (rather than to average where things should not be averaged). SCDs constitute a wonderful tool for research and practice in specific institutions as well as for multi-institution studies that are part of national or international collaborative projects. Recent years have resulted in parametric and nonparametric models for different types of data, which make SCDs useful regardless of the type of data we are considering. These questions and developments in combination make that the time for SCDs in HPE has come. Institutions and centres should be encouraged to use SCDs to answer local questions and serve local needs, and to document and publish findings arising from such SCDs so others can learn from these findings and design similar studies in their local contexts. Additionally, institutions and centres should consider the use of SCDs in multi-institution or multi-centre collaborations. Both ways can facilitate generalisability through meta-analysis and systematic review.

Note on Contributor

This manuscript has one author who wrote the full letter and meets all four criteria of authorship listed under International Committee of Medical Journal Editors (ICMJE); there were no other authors contributing to this letter.

Funding

No funds, grants or other support was received.

Declaration of Interest

No conflicts of interest are associated with this paper.

References

Johnson, R. B., & Onwuegbuzie, A. J. (2004). Mixed methods research: A research paradigm whose time has come. Educational Researcher, 33(7), 14-26. https://doi.org/10.3102/0013189X033007014

Leppink, J. (2020). The art of modelling the learning process: Uniting educational research and practice. Springer. https://doi.org/10.1007/978-3-030-21241-4

Nickson, C. P., Petrosoniak, A., Barwick, S., & Brazil, V. (2021). Translational simulation: From description to action. BMC Advances in Simulation, 6(6), 1-11. https://doi.org/10.1186/s41077-021-00160-6

Prideaux, D. (2019). The global-local tension in medical education: Turning ‘think global, act local’ on its head? Medical Education, 53(1), 25-31. https://doi.org/10.1111/medu.13630

Van de Schoot, R., & Miocevic, M. (2020). Small sample size solutions: A guide for applied researchers and practitioners. Routledge. https://doi.org/10.4324/9780429273872

*Jimmie Leppink
Avenida de Valdecilla,
s/n, 39008, Santander, Spain
Email: jleppink@hvvaldecilla.es

Submitted: 4 May 2021
Accepted: 22 July 2021
Published online: 4 January, TAPS 2022, 7(1), 106-108
https://doi.org/10.29060/TAPS.2022-7-1/PV2532

Shamalee Wasana Jayarathne¹ & Lambert Schuwirth²

¹Medical Education Unit, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Sri Lanka; ²Prideaux Centre for Research in Health Professions Education, Flinders University, Australia

Medical Professional Identity Formation (PIF) has been suggested as a fundamental outcome in medical education (Cruess et al., 2014). Medical professional identity is development of both personal and professional identity as a physician. PIF achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalised, resulting in individual thinking, acting, and feeling like a physician (Cruess et al., 2014).  It is basically not a process of learning to demonstrate professional behaviour but of change into a “professional being” or professional physician. Throughout the journey of PIF, moments of dissonance between personal values and professional values are likely to occur. So logically, there will be phases of learning and unlearning. Learning is generally well-defined, but unlearning has been conceptualised through different lenses both on the process of unlearning and the unlearnt content, leading to conflicting views.

Unlearning has been conceptualised through different lenses. Hislop et al. (2014) have described unlearning as “abandoning or giving up knowledge or behaviours without making any judgement on the status of the knowledge or behaviours being unlearned”. In addition, Macdonald (2002) has explained unlearning in terms of transformative unlearning, which is as a process of questioning, reflecting and giving up some core values, assumptions, knowledge and practices. On the other hand, some authors have given subjective value to unlearnt knowledge and practices. Srithika and Bhattacharyya (2009) have defined unlearning as a process that includes judging the knowledge, values or practices with current knowledge. If current knowledge is superior to previous knowledge, individuals do unlearn previous knowledge. In this background, we hypothesise unlearning to be a meta-cognitive process and not as a permanent loss of something. Instead, we recognise it as a person consciously discarding, abandoning, or giving up particular values, knowledge, or behaviour and consciously choosing not to continue using them; a meta-cognitive process.

Several authors have categorised unlearning in various ways, which leads to sometimes conflicting views on the characteristics of the process of unlearning. Rushmer and Davies (2004) have categorised unlearning into three categories namely, ‘fading’, ‘wiping’ and ‘deep unlearning’. Fading occurs due to lack of use and it occurs over time. Wiping is deliberate process, occurs due to external change or due to an experience. Wiping is a process in which unlearning of behaviours and complex social learning (beliefs, values, attitudes, assumptions, and interpersonal skills) happens. Deep unlearning was defined as a “sudden, unexpected, and potentially painful event that ruptures part of our way of being or deeply held understanding of the world” (Rushmer & Davies, 2004). They further explained that deep unlearning occurs in an unpredictable, disruptive way and it is less planned and less deliberate. It trigged by a sudden action or an event (Rushmer & Davies, 2004). Although, transformative unlearning is defined similar to the concept of deep unlearning, the characteristics of the process of unlearning are rather conflicting in deep unlearning and transformative unlearning. Transformative unlearning is conceptualised as a process of reflecting upon, questioning and giving up some values, assumptions and practices (Macdonald, 2002). This transformative unlearning process has three phases which are “receptiveness, recognition and grieving”. Hence, during this process a “person loses prior ways of seeing [which] until now had brought certainty and security”.  However, this is a slow process.

There is a scarcity of empirical studies found in relation to individual unlearning process. One study in the UK explored health care managers’ engagement in unlearning and the impact of unlearning in decision making (Coombs et al., 2013). Authors distinguished two types of unlearning based on these health care managers’ experiences: “behavioural unlearning” and “cognitive unlearning”.  Behavioural unlearning has similarities with wiping, whereas cognitive unlearning has similarities with deep unlearning. Behavioural unlearning is triggered by a deliberate process of change that had been externally imposed, while deep unlearning is triggered by questioning individuals’ basic assumptions due to an external event. Hence, the descriptions on characteristics of process of unlearning is conflicting in deep unlearning, transformative unlearning and cognitive unlearning and it is worth further exploration.

It is important to recognise the similarities and differences between to forgetting and unlearning. Some researchers tend to use unlearning and forgetting interchangeably (Rushmer & Davies, 2004). According to Rushmer and Davies (2004) fading occurs due to lack of use and it occurs over time. This is not an intentional action and it equals to forgetting. However, they have conceptualised fading under the concept of unlearning, which is questionable.  Equally, several authors observed the contrasting nature of unlearning and forgetting. They distinguish the deliberate, conscious nature of unlearning (Coombs et al., 2013) from unintentional nature of forgetting. Our stance is that forgetting as loss of knowledge not necessarily planned or intended, which is distinct from unlearning.

Although there is conflicting conceptual literature, the concept of unlearning is worthwhile to explore; especially the different conceptual models of ‘transformative unlearning’ (Macdonald, 2002) ‘deep unlearning’ (Rushmer & Davies, 2004) and cognitive unlearning (Coombs et al., 2013) in relation to PIF in physicians. Unlearning is important in PIF process, because an inability to give up values, norms, practices when they no longer match the demand of one’s current perspectives inevitably leads to rigidity in thinking and lack of flexibility. It is plausible that individuals who enter into the career of medicine have their own personal values and assumptions or specific world views. But professional values of medicine are often a set of values defined by society and public. It is proven that, professional attributes are contextually depended. Physicians need to keep to these professional values based on the context in which they work. During the journey of PIF moments of dissonance between personal values and professional values are likely to occur. These can be struggling points for both medical students and physicians while they unlearn their worldviews and replace them by new or adapted ones. Also, there are still many unclear areas concerning PIF and unlearning. For instance, can individuals unlearn deep values and assumptions? would that process really entail deep unlearning or merely wiping? Why is this unlearning cognitively and emotionally challenging for some individuals?  Exactly how does unlearning of deep values and assumptions of individuals occur during PIF of physicians is currently under-researched. Thus, understanding the process of professional identity formation in the light of unlearning of deep values and assumptions of individuals is important in medical education to support journey of PIF of physicians and medical students.

Notes on Contributors

YGSW Jayarathne, MBBS, PG Dip in MEd, MD in MEd is a Senior Lecturer in Medical Education and was involved the conceptual development, argument building, ethics application and the development of the manuscript.  

Lambert Schuwirth, MBBS, MD, PhD, FANZHPE is a Professor of Medical Education and Director Prideaux Centre for Research in Health Professions Education, College of Medicine and Public Health, Flinders University and was involved the conceptual development, argument building and the development of the manuscript.

Acknowledgement

No acknowledgement is associated with this paper.

Funding

No funding sources are associated with this paper.

Declaration of Interest

There are no conflicts of interests related to the content presented in the paper.

References

Coombs, C. R., Hislop, D., Holland, J., Bosley, S. L. C., & Manful, E. (2013). Exploring types of individual unlearning by local health-care managers: An original empirical approach. Health Services and Delivery Research, 1(2), 1–146.

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2014). Reframing medical education to support professional identity formation. Academic Medicine, 89(11), 1446-1451. https://doi.org/10.1097/ACM.0000000000000427

Hislop, D., Bosley, S., Coombs, C. R., & Holland, J. (2014). The process of individual unlearning: A neglected topic in an under-researched field. Management Learning, 45(5), 540-560. https://doi.org/10.1177/1350507613486423

Macdonald, G. (2002). Transformative unlearning: Safety, discernment and communities of learning. Nursing Inquiry, 9(3), 170-178. https://doi.org/10.1046/j.1440-1800.2002.00150.x

Rushmer, R., & Davies, H. T. (2004). Unlearning in health care. BMJ Quality and Safety, 13(Suppl 2), 10-15. https://doi.org/10.1136/qshc.2003.009506

Srithika, T. M., & Bhattacharyya, S. (2009). Facilitating organizational unlearning using appreciative inquiry as an intervention. Vikalpa, 34(4), 67-78. https://doi.org/10.1177/0256090920090406

*YG Shamalee Wasana Jayarathne
Medical Education Unit,
Faculty of Medicine and Allied Sciences,
Rajarata University of Sri Lanka
Email: wasana@med.rjt.ac.lk, wjayaratna@yahoo.com

Submitted: 22 December 2020
Accepted: 8 February 2021
Published online: 5 October, TAPS 2021, 6(4), 146-147
https://doi.org/10.29060/TAPS.2021-6-4/PV2453

Simon Tso

Jephson Dermatology Centre, South Warwickshire NHS Foundation Trust, United Kingdom

Continuing professional development (CPD) is a professional obligation of clinicians aiming to ‘improve the safety and quality of care provided for patients and the public’ and ‘covers the development of your knowledge, skills, attitudes and behaviours across all areas of your professional practice’ (General Medical Council UK, 2020). The professional practice of clinicians is highly variable and may include clinical practice, management, education, academia and research, media and public engagement, advisory to charities and pharmaceutical companies, politics, and working for the government. Despite the varied role of clinicians, literature suggested that clinicians undertake the majority of their CPD in their specialist areas, although many clinicians are also interested in undertaking CPD in areas outside their specialty (Maher et al., 2017).

The year of 2020 was a challenging and sobering year for clinicians across the world with redeployment of clinicians from many specialities to undertake activities they were less familiar with (Seah, 2020). The phrase ‘CPD’ took on a new personal meaning through the change of my role as a consultant dermatologist during the COVID-19 pandemic and an unsuccessful application for a National Institute for Health Research (UK) advanced research fellowship so that I can establish myself as an independent researcher.

I volunteered to help with COVID-19 research at my employing hospital, but unexpectedly found myself becoming a site principal investigator for the UK nationally prioritised Randomised Evaluation of COVID-19 Therapy (RECOVERY Trial) that led to the discovery of dexamethasone as a treatment for COVID-19 hospitalised patients requiring oxygen therapy or ventilation support (RECOVERY Collaborative Group et al., 2021). It was a baptism of fire learning to manage and deliver the clinical trial while frantically trying to familiarise myself with the literature on pharmacology of trial medicinal products, human physiology and COVID-19 literature. I sought the counsel from my hospital’s senior research nurses, and research manager to jointly govern and deliver the trial at my hospital; and I also talked to colleagues and doctors in training to learn about the practicalities of managing COVID-19 patients in clinical settings. I kept records of my CPD related to COVID-19, reflected upon these experiences in my learning portfolio and discussed these experiences in my annual appraisal. These records also serve as evidence to justify my practices outside my area of specialism. Although I may possess relevant transferable skills and experience that facilitates me to lead and undertake work outside my speciality during the unprecedented time of the pandemic, it is important to maintain insight about our own limitations; learn from different resources; seek and accept help from others in a position of knowledge and experience whoever they may be, as this is crucial for delivering a safe service.

Despite my portfolio of varied research experience and higher research degree, I once held the wishful thinking that I could directly transition into an independent researcher due to my clinical role as a consultant. The feedback I received from the unsuccessful advanced research fellowship application has encouraged much needed reflexivity into my own strengths and limitations, and successfully challenged the naïve viewpoint that I once held. A consultant transitioning into an independent researcher is not an automatic process, but requires the progressive development of experience and credentials to justify the award of an advanced fellowship and it is ok to start from the beginning.

The literature described three broad categories of career paths: progressive, by chance and enthusiasts (Tuononen et al., 2018). CPD was crucial to my progressive career development into a consultant dermatologist and help me keep abreast with the latest evidence based clinical practices. Just-in-time CPD was important for me to discharge my leadership role as a site principal investigator in the RECOVERY Trial that I took on by chance as it was important for me to become knowledgeable about the topic and take responsibility about every aspect of the trial delivered at my site. I am enthusiastic about research and CPD is one of the many tools that can help me build the skills necessary to pursue clinical academia.

In conclusion, CPD is not just a professional obligation to keep ourselves up to date about evidence based practices in our specialty to deliver safe and high quality patient care, it is also a valuable tool to help us maintain our generalist knowledge outside our specialty (which we may rely upon if we get redeployed) and prepare us to reconfigure our career path.

Note on Contributor

Dr Simon Tso is a consultant dermatologist at the South Warwickshire NHS Foundation Trust, United Kingdom. He was responsible for conception and design of the work reported in the manuscript, reviewed the literature, drafted the manuscript and approved the final version of the manuscript submitted.

Acknowledgement

The author would like to thank his clinical and research work colleagues for their support throughout the pandemic.

Funding

There is no funding source required for this study. 

Declaration of Interest

The author report no conflict of interest. The author is responsible for the content and writing of the article.

References

General Medical Council. (2020, December 11). Continuing professional development. General Medical Council United Kingdom. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/continuing-professional-development

Maher, B., Faruqui, A., Horgan, M., Bergin, C., Tuathaigh, C. O., & Bennett, D. (2017). Continuing professional development and Irish hospital doctors: A survey of current use and future needs. Clinical Medicine (London), 17(4), 307-315. https://doi.org/ 10.7861/clinmedicine.17-4-307

RECOVERY Collaborative Group., Horby, P., Lim, W. S., Emberson, J. R., Mafham, M., Bell, J. L., Linsell, L., Staplin, N., Brightling, C., Ustianowski, A., Elmahi, E., Prudon, B., Green, C., Felton, T., Chadwick, D., Rege, K., Fegan, C., Chappell, L. C., Faust, S. N., … Landray, M. J. (2021). Dexamethasone in Hospitalized Patients with Covid-19. The New England Journal of Medicine, 384(8), 693–704. https://doi.org/10.1056/NEJMoa2021436

Seah, K. M. (2020). Redeployment in COVID-19: Old dogs and new tricks. Emergency Medicine Journal, 37(7), 456. https://doi.org/ 10.1136/emermed-2020-210052

Tuononen, T. A., Suominen, A. L., & Lammintakanen, J. (2018). Career path from a dentist to a leader. Leadership in Health Services (Bradford England), 31(4), 384-397. https://doi.org/ 10.1108/LHS-08-2017-0051

*Simon Tso
Jephson Dermatology Centre,
South Warwickshire NHS Foundation Trust,
Warwick,
CV34 5BW, United Kingdom.
Tel: 01926495321 Ext 4569
Email: simontso@doctors.org.uk

Submitted: 14 July 2020
Accepted: 16 September 2020
Published online: 13 July, TAPS 2021, 6(3), 99-103
https://doi.org/10.29060/TAPS.2021-6-3/PV2343

Colleen Cheek^1,2, Richard Hays³ & Janie Smith²

¹Education and Research, Tasmania Health Service North West, Australia; ²Faculty of Health Sciences and Medicine, Bond University, Australia; ³Centre for Rural & Remote Health, James Cook University, Australia

I. INTRODUCTION

Research ability is considered important in preparing medical graduates for their future work roles, providing openness to critical inquiry and astute information management (Frenk et al., 2010). The role of knowledge integrator, facilitator, and advisor, incorporating finely-tuned judgement, reasoning and decision-making, are important in achieving the leadership expected of the profession (Frenk et al., 2010). Engaging medical students in research training has historically proven challenging, and there is variable understanding of the level expected in primary medical training.

Most medical schools in Australia have now adopted a Master’s Level ‘Medical Doctorate’ (MD) for primary medical training. Both the Australian Qualifications Framework (2013) requirements (pertaining to the level of qualification) and the Australian Medical Council (AMC) standards (pertaining to the profession) expect graduates of an MD to have understanding of research principles, process and methods, and to be able to apply these to professional practice (Australian Medical Council Limited, 2012). Many schools have interpreted this as a requirement for more intensive research training. While research knowledge and skills are integrated throughout curricula, there is substantial variation in the way these are taught, and little evidence of effective learning exists.  

Varying approaches to align courses internationally may have muddied the situation further. For example, in the UK, primary medical training is considered to meet the requirements of a UK Level 7 Master’s Degree, although most programmes have retained historical titles of Bachelor of Medicine, Bachelor of Surgery, abbreviated as BM BS or MBChB. In Canada, graduates of primary medical training are awarded the degree of Doctor of Medicine (MD) but are considered to have achieved academic outcomes at Bachelor level. In the US, graduates of primary medical training are awarded the degree of Doctor of Medicine (MD) and widely assumed to achieve Master’s level learning outcomes. European medical schools, through conformance with the Bologna Declaration, are tending toward a 2nd cycle, or Master’s degree. In the Asia-Pacific region, Singapore retains a Bachelor of Medicine, Bachelor of Surgery (MBBS), as do Malaysia (a Level 6 Bachelor degree), Japan and New Zealand. In Australia, there are some Bachelor (Level 7) programmes but most medical schools have adopted a Master’s Degree (Extended) (Level 9E) for primary medical training, conferring a ‘Medical Doctorate’ (MD). In these examples there is little correlation between learning outcome levels and programme duration, which ranges from four to six years. 

 A. Defining Learning Outcomes and the Level of Understanding Required

The most recent standards of the World Federation for Medical Education promote ‘constructively aligned’ medical education. That is, teaching activities and assessment aligned with student-centred learning outcomes where the type of knowledge, whether declarative (book knowledge) or functional (professional know-how required in the workplace), and the level of understanding required are clear. 

The level of understanding can be mapped from taxonomies of action verbs. The Structure of Observed Learning Outcomes (SOLO) is one taxonomy (Biggs & Collis, 2014). It consists of five levels of understanding that reflect increasing learning complexity. The first is pre-structural (no understanding); through uni-structural and multi-structural (representing two stages of qualitative comprehension) to relational and extended abstract. The verbs ‘order’ and ‘compute’ might describe learning action at uni- and multi-structural stages, whereas ‘construct’ and ‘extrapolate’ describe learning action at relational and extended abstract stages. Once learning outcomes are explicit, decisions about teaching activities that will allow the student to achieve the learning outcomes can be made. For example, functional knowledge verbs e.g. ‘assess’ or ‘reflect’, reflects activity performed in the workplace (ideally), or an authentic simulated environment.   

Here we provide a perspective of the research knowledge and skills required of graduates of an Australian MD to promote shared understanding of the level of learning and the key elements for orientating teaching to medical practice.

II. METHODS

To define the Individual Learning Outcomes (ILO)  relating to research competency in Australia, the Level 9E Australian Qualifications Framework (AQF) criteria and descriptors (Australian Qualifications Framework, 2013) and the AMC standards and graduate outcomes (Australian Medical Council Limited, 2012) that pertained to research knowledge and skills were collated (Appendix 1). Using the SOLO taxonomy (Biggs & Collis, 2014), the types of knowledge and the required level of understanding was determined (Appendix 2).

III. RESULTS

Three issues emerged. The first was that the highest levels of understanding required (extended abstract), pertain to functional knowledge such as critically analysing information, reflecting on and applying theory. Graduates are expected to have ‘expert’ knowledge and abilities in this area based on ‘research, experience or occupation’. This may imply that achieving the higher-level learning outcomes requires a substantial research experience, such as a completed project that engages students in all aspects of planning, conducting, and reporting research. This reflects what happens during the AQF Level 10 (doctoral level) research training and may be difficult to achieve during a Level 9E programme.    

The second was that a high level of functional knowledge (relational) is required to plan and execute project work, reflecting the more traditional, Master’s (Research) programme. This should be achievable during Master’s (extended) programmes if the learning takes place over time and provides ‘reasonable’ experience in aspects of research. For this to fit in with the clinical immersion learning experience, such projects should engage students with healthcare delivery.   

The third was that a fairly high, but lower level of declarative knowledge (multi-structural and relational) is required pertaining to scientific methods, ethical and privacy principles, and these should be heavily grounded in application to the profession. This is consistent with the inclusion of research training modules in coursework, but without a requirement to complete a research project.

IV. DISCUSSION

Medical curricula should constantly evolve to meet the perceived needs of the changing population and health systems. Cooke et al. (2010) tell us that the virtues of being curious, of being open to further learning, taking time to consider different perspectives and weigh up the options are metacognitive skills that should be developed early in medical training to cultivate lifelong learning and drive for continuing improvement in health systems. The emphasis in current medical education commentary is to provide options and electives for flexible, student-led approaches to learning.

The AMC graduate outcomes (Australian Medical Council Limited, 2012) affirm that a critical component of developing competency as a doctor is the opportunity to hone generic skills such as communication and teamwork and apply developing knowledge through authentic experience in the clinical setting. Functional knowledge is demonstrated through project work conducted (ideally) in real work settings. This experience provides opportunities to learn to adapt to unforeseen medical problems and to learn interactive and reflective skills important in achieving both specialist professional performance and life-long learning. Fostering knowledge and skills in seeking information, considering alternatives, collaborating, making decisions, planning and executing the plan may better prepare medical professionals for leadership roles that are required of responsive health systems where emerging technology and global forces are likely to drive adaptation and reform. Facets of critical inquiry, such as recognising a knowledge gap, seeking information, seeing multiple perspectives, taking time to consider alternatives and then make a judgement, are also qualities of an adaptive leader. Achieving all of this through a completed research project during primary medical education is challenging. Performing one component well may be enough if it is known how the component fits as part of the whole.

Specific requirements for knowledge and skills in research and their application are still inherent in both AQF and AMC standards. Expertise in defining a searchable question and finding and assessing the evidence are realistic and useful goals for primary medical training and are professionally relevant to the work of doctors in the 21st century. Conducting literature reviews about topics that matter to the local community can be achieved in primary training. There are models of collaboration within healthcare settings where medical students are supported in a community of practice with more senior doctors overseeing local quality improvement projects. Quality improvement projects in Primary Care offer further opportunity.

There may be other ways of achieving Master’s level learning outcomes that do not require research experience, as some students are not ready for this. Examples include project work in professional and capstone settings, where students performed skills associated with developing leadership and management competency in a range of different contexts.

V. CONCLUSION

Achieving higher-order thinking by the end of primary medical education is emerging as crucial to graduating doctors who are better prepared for managing the future challenges of healthcare. Integration of research thinking with work-based experience may be the critical attribute to foster this and may also be achieved through professional and capstone projects. There is a case for providing stronger guidance on just what is intended and achievable within the constraints of contemporary medical education. It is unlikely that the move to Master’s level programmes in Australia will on its own result in more research capable graduates; more important may be how students are introduced to research knowledge and practical experiences. However, adopting Master’s level outcomes as the endpoint may improve consistency in achievement of higher-level thinking and the inferred ability to find solutions to challenges as healthcare evolves. 

Notes on Contributors

Colleen Cheek developed the methodological framework for the study, performed data collection and data analysis as part her PhD research project, and wrote the manuscript, collated edits and approved the final manuscript.

Richard Hays reviewed the study design and interpretation and developed the manuscript, read and approved the final manuscript.

Janie Smith reviewed the design of the study and gave critical feedback to the writing of the manuscript, read and approved the final manuscript.

Funding

No funding source was required.

Declaration of Interest

We have no conflict of interest to declare.

References

Australian Medical Council Limited. (2012). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council. https://www.amc.org.au/wp-content/uploads/2019/10/Standards-for-Assessment-and-Accreditation-of-Primary-Medical-Programs-by-the-Australian-Medical-Council-2012.pdf

Australian Qualifications Framework. (2013). Australian Qualifications Framework (2^nd ed.). https://www.aqf.edu.au/sites/aqf/files/aqf-2nd-edition-january-2013.pdf.

Biggs, J. B., & Collis, K. F. (2014). Evaluating the quality of learning: The SOLO taxonomy (Structure of the observed learning outcome). Academic Press.    

Cooke, M., Irby, D. M., & O’Brien, B. C. (2010). Educating physicians: A call for reform of medical school and residency (Vol. 16). John Wiley & Sons.

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*Colleen Cheek
ADON Education and Research,
Tasmania Health Service North West
PO Box 258, Burnie 7320
Email: Colleen.Cheek@ths.tas.gov.au