Counternarratives that illuminate faculty agency: A five-year longitudinal qualitative study of physician educators in academic medicine.

PURPOSE: Physician educators are often expected to direct educational programs and assume roles that conform to field norms for career advancement but that may not afford meaningful work for educators. The purpose of this study was to describe and analyse the perspectives and actions taken by physician educators in response to tension between feeling compelled to direct an educational program and doing educationally meaningful work. METHODS AND MATERIALS: We used data from a longitudinal study and focused on three participants who, over the course of the five-year study, offered significant insights into how physician educators act in ways that run counter to expectations for career advancement. Our narrative analysis entailed organizing data from interview transcripts into time-ordered displays, weaving data into counternarratives that were edited by participants, and using the theory of faculty agency (and its key constructs, strategic perspectives and strategic action) to thread the stories together. RESULTS: In each counternarrative, the participant deliberated their sense of being a physician educator (strategic perspectives) and when expectations became untenable, they did what they needed to do to engage in meaningful work (strategic action) rather than comply with expectations for career advancement in academic medicine. For one participant, faculty agency meant leaving academic medicine; for another, it meant reducing clinical time so that unpaid time could be devoted to education; and for another, it meant opting not do direct a reputable education program. CONCLUSIONS: Faculty agency is a useful theoretical lens for conceptualizing how physician educators navigate their careers in academic medicine. Counternarratives that illuminate faculty agency offer stories that describe alternate career paths and portend a different future for physician educators.

Inequity is woven into the fabric: a discourse analysis of assessment in pediatric residency training.

Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.

EKG Acquisition Curriculum for Pediatric Trainees.

OBJECTIVES: Pediatric residency trainees interface with electrocardiograms (EKG) as part of routine clinical care. Depending on workflow and availability of support staff, trainees may be required to obtain EKGs on patients, though training on this skill varies. Our intervention seeks to train incoming pediatric residents on obtaining EKGs from pediatric patients and identifying common problems that may result in acquisition of low-fidelity EKGs. METHODS: A team of physicians, EKG technicians, and simulation educators designed a 30-min didactic and experiential learning opportunity for incoming pediatric trainees held prior to their start of clinical responsibilities. During the session, trainees were introduced to the basics of EKG acquisition and common quality issues that arise. Afterwards, they practiced placing EKG leads on a mannequin and a live model. A pre- and post-session survey was utilized to assess the session's utility and participant's learning. RESULTS: The intervention was perceived as a valuable experience by participants over the course of 2 years. We found increased participant comfort with performing and troubleshooting EKGs (P<.001). There was a 33% improvement in quality assessment of EKG rhythm strips after the session (P<.001). CONCLUSION: Given the importance of EKGs to the care of pediatric patients, it is essential that pediatricians receive adequate training in acquiring and assessing EKG quality. This intervention was deemed to be highly useful with a demonstrated improvement in EKG troubleshooting skills among first year pediatric residents. This session improves learner comfort with essential clinical responsibilities and identification of low-quality EKGs that often warrant repeat testing.

Program Evaluation in Health Professions Education: An Innovative Approach Guided by Principles.

PROBLEM: Program evaluation approaches that center the achievement of specific, measurable, achievable, realistic, and time-bound goals are common in health professions education (HPE) but can be challenging to articulate when evaluating emergent programs. Principles-focused evaluation is an alternative approach to program evaluation that centers on adherence to guiding principles, not achievement of goals. The authors describe their innovative application of principles-focused evaluation to an emergent HPE program. APPROACH: The authors applied principles-focused evaluation to the Children's Hospital of Philadelphia Medical Education Collaboratory, a works-in-progress program for HPE scholarship. In September 2019, the authors drafted 3 guiding principles. In May 2021, they used feedback from Collaboratory attendees to revise the guiding principles: Advance Excellence , Build Bridges , and Cultivate Learning . OUTCOMES: In July 2021, the authors queried participants about the extent to which their experience with the Collaboratory adhered to the revised guiding principles. Twenty of the 38 Collaboratory participants (53%) responded to the survey. Regarding the guiding principle Advance Excellence , 9 respondents (45%) reported that the Collaboratory facilitated engagement in scholarly conversation only by a small extent, and 8 (40%) reported it facilitated professional growth only by a small extent. Although some respondents expressed positive regard for the high degree of rigor promoted by the Collaboratory, others felt discouraged because this degree of rigor seemed unachievable. Regarding the guiding principle Build Bridges , 19 (95%) reported the Collaboratory welcomed perspectives within the group. Regarding the guiding principle Cultivate Learning , 19 (95%) indicated the Collaboratory welcomed perspectives within the group and across disciplines, and garnered collaboration. NEXT STEPS: Next steps include improving adherence to the principle of Advancing Excellence , fostering a shared mental model of the Collaboratory's guiding principles, and applying a principles-focused approach to the evaluation of multi-site HPE programs.

Diagnostic Reasoning of Resident Physicians in the Age of Clinical Pathways.

Background: Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described. Objective: To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning. Methods: We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework. Results: Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process. Conclusions: This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.

Can I Ask a Question About URiM Awards That I Don't Know the Answer to? Designing an Award for Underrepresented Medical Education Researchers.

Meaningful Equity, Diversity, and Inclusion (EDI) efforts may be stymied by concerns about whether proposed initiatives are performative or tokenistic. The purpose of this project was to analyze discussions by the Research in Medical Education (RIME) Program Planning committee about how best to recognize and support underrepresented in medicine (URiM) researchers in medical education to generate lessons learned that might inform local, national, and international actions to implement meaningful EDI initiatives. Ten RIME Program Planning Committee members and administrative staff participated in a focus group held virtually in August 2021. Focus group questions elicited opinions about "if and how" to establish a URiM research award. The focus group was recorded, transcribed, and thematically analyzed. Recognition of privilege, including who has it and who doesn't, underpinned the focus group discussion, which revolved around 2 themes: (1) tensions between optics and semantics, and (2) potential unintended consequences of trying to level the medical education playing field. The overarching storyline threaded throughout the focus group discussion was intentionality. Focus group participants sought to avoid performativity by creating an award that would be meaningful to recipients and to career gatekeepers such as department chairs and promotion and tenure committees. Ultimately, participants decided to create an award that focused on exemplary Equity, Diversity, and Inclusion (EDI) scholarship, which was eventually named the "RIME URiM Research Award." Difficult but productive conversations about EDI initiatives are necessary to advance underrepresented in medicine (URiM) scholarship. This transparent commentary may trigger further critical conversations.

Replace, amplify, transform: a qualitative study of how postgraduate trainees and supervisors experience and use telehealth for instruction in ambulatory patient care.

BACKGROUND: Little is known about using telehealth patient visits as an educational mode. Therefore, rapid implementation of telehealth during the COVID-19 pandemic had to be done without understanding how to optimize telehealth for education. With the likely sustained/post-pandemic use of telehealth in ambulatory patient care, filling gaps in our understanding of how telehealth can be used for instruction in this context is critical. This study sought to understand perceptions of pediatric postgraduate trainees and supervisors on the use of telehealth for instruction in ambulatory settings with the goal of identifying effective ways to enhance learning during telehealth visits. METHODS: In May-June of 2020, the authors purposefully sampled first- and third-year postgraduate trainees and supervising attendings from pediatric fellowship programs at one institution that implemented telehealth for instructional activities. They conducted semi-structured interviews; interviews lasted a median of 51 min (trainees) and 41 min (supervisors). They conducted interviews and data analysis iteratively until reaching saturation. Using thematic analysis, they created codes and constructed themes from coded data. They organized themes using the Replace-Amplify-Transform (RAT) model, which proposes that technology can replace in-person learning and/or amplify and transform learning. RESULTS: First-year trainees (n = 6), third-year trainees (n = 5) and supervisors (n = 6) initially used telehealth to replace in-person learning. However, skills that could be practiced in telehealth visits differed from in-person visits and instructional activities felt rushed or awkward. Trainees and supervisors adapted and used telehealth to amplify learning by enhancing observation and autonomy. They also transformed learning, using telehealth to develop novel skills. CONCLUSIONS: To harness telehealth for instructional activities, our findings indicated that trainees and supervisors should shift from using it as a direct replacement for in-person education to taking advantage of novel opportunities to amplify and transform education in PGME. The authors provide data-driven recommendations to help PGME trainees, supervisors and educators capitalize on the educational advantages of telehealth.

Conducting qualitative research through time: how might theory be useful in longitudinal qualitative research?

This paper explores the use of theory in longitudinal qualitative research, an approach to research which explores lived experiences as they unfold. The authors illustrate how the complexity of conducting qualitative research through time drives an understanding and use of theory that differs from other research approaches. Longitudinal qualitative research considers time as fluid, subjective, and unbounded-in contrast to the more common taken-for-granted understanding of time as fixed, objective, and linear. Furthermore, longitudinal qualitative research is predicated on a premise of trust in the context of enduring research relationships. Therefore, while subject-matter theories used to investigate topics of interest to health professions educators may be useful frameworks for other types of research, longitudinal qualitative research needs theories that accommodate the myriad of changes in lived experiences through time. The authors share their decade-long, longitudinal qualitative research story, highlighting their decision points and insights. In doing so, they foreground issues such as time as fluid as an important contribution to health professions education literature.

Longitudinal Qualitative Study of Career Decision-making of First-Year Medical Students: Why Neurology (or Not)?

OBJECTIVE: The growing shortage of neurologists is in part due to suboptimal recruitment. Little is known about students' decision making regarding a career in neurology, particularly early in training. Using a longitudinal qualitative approach, we aimed to understand factors that influence first-year medical students' decisions about neurology. METHODS: We conducted 1-on-1 semistructured interviews with 15 first-year medical students at 1 institution before and after the preclinical neurology course (2018-2019). In the first interview, we asked about career intentions, factors likely to influence specialty choice, and perceptions of neurology. In the second interview, we asked about changes in students' views over the year. Using thematic analysis, we generated codes and clustered coded data into themes. RESULTS: The 2 most prominent factors influencing career choice in general were lifestyle and personal interest. No students expressed concerns about lifestyle in neurology. Most students were neutral about neurology or had a positive personal interest, which typically increased after the neurology course. Students frequently worried about content difficulty and the curative potential of neurology. CONCLUSIONS: Interventions should include early education about the factors important to students in determining specialty choice, including lifestyle, and address potentially negative perceptions of neurology. Increasing time allotment to the preclinical neurology course may combat perception of the content as difficult.

RIME 60 Years: Celebration and Future Horizons.

This year marks the 60th anniversary (1961-2021) of Research in Medical Education (RIME). Over the past 6 decades, RIME has selected medical education research to be presented each year at the Association of American Medical Colleges Annual Meeting: Learn Serve Lead and published in a supplement of Academic Medicine. In this article, the authors surveyed RIME chairs from the past 20 years to identify ways that RIME has advanced medical education research and to generate ideas for future directions. RIME chairs described advancements in the rigor and impact of RIME research and the timeliness of the topics, often serving as a driver for cutting-edge research. They highlighted RIME's role in promoting qualitative research, introducing new epistemologies, and encouraging networking as a means of career advancement. Going forward, RIME chairs suggested (1) strengthening collaborations with formal advanced MEd and PhD degree programs, (2) creating formal mentorship channels for junior and minority faculty, and (3) promoting research related to knowledge translation.