Unravelling epistemic injustice in medical education: The case of the underperforming learner.

CONTEXT: Epistemic injustice refers to a wrong done to someone in their capacity as a knower. While philosophers have detailed the pervasiveness of this issue within healthcare, it is only beginning to be discussed by medical educators. The purpose of this article is to expand the field's understanding of this concept and to demonstrate how it can be used to reframe complex problems in medical education. METHODS: After outlining the basic features of epistemic injustice, we clarify its intended (and unintended) meaning and detail what is required for a perceived harm to be named an epistemic injustice. Using an example from our own work on introversion in undergraduate medical education, we illustrate what epistemic injustice might look like from the perspectives of both educators and students and show how the concept can reorient our perspective on academic underperformance. RESULTS: Epistemic injustice results from two things: (1) social power dynamics that give some individuals control over others, and (2) identity prejudice that is associated with discriminatory stereotypes. This can lead to one, or both, forms of epistemic injustice: testimonial and hermeneutical. Our worked example demonstrates how medical educators can be unaware of when and how epistemic injustice is happening, yet the effects on students' well-being and sense of selves can be profound. Thinking about academic underperformance with epistemic injustice in mind can reveal an emphasis within current educational practices on diagnosing learning deficiencies, to the detriment of holistically representing its socially constructed and structural nature. CONCLUSIONS: This article builds upon recent calls to recognise epistemic injustice in medical education by clarifying its terminology and intended use and providing in-depth application and analysis to a particular case: underperformance and the introverted medical student. Equipped with a more sophisticated understanding of the term, medical educators may be able to re-conceptualise long-standing issues including, but also beyond, underperformance.

A narrative inquiry into non-Indigenous medical educators and leaders participation in reconcilatory work.

INTRODUCTION: Globally, medical schools are operationalising policies and programming to address Indigenous health inequities. Although progress has been made, challenges persist. In Canada, where this research is conducted, Indigenous representation within medical schools remains low, leaving a small number of Indigenous advocates leading unprecedented levels of equity-related work, often with insufficient resources. The change needed within medical education cannot fall solely on the shoulders of Indigenous Peoples; non-Indigenous Peoples must also be involved. This work aims to better understand the pathways of those engaged in this work, with careful consideration given to the facilitators and barriers to ongoing engagement. METHODS: Data collection and analysis were informed by narrative inquiry, a methodology that relies on storytelling to uncover nuance and prompt reflection. In this paper, we focus on interview data collected from Canadian non-Indigenous medical educators and leaders (n = 10). Participants represented different career stages, (early to late career) and occupied a mix of clinical, administrative and education roles. RESULTS: Although each participant's entry into reconciliatory work was unique, we identified common drivers actuating their engagement. Oftentimes their participation was tied to administrative work or propelled by experiences within their roles that forced them to confront the systemic inequalities borne by Indigenous Peoples in both academic and healthcare settings. Some admitted to struggling with understanding their appropriate role in Indigenous reconciliation; their participation often proceeded without firm support. CONCLUSION: Medical schools have an obligation to ensure their faculty, including non-Indigenous Peoples, are equipped to fulfil social accountability mandates regarding Indigenous health. Our findings generate a better understanding of the tensions inherent in this equity work. We urge others to reflect on their role in Indigenous reconciliation, or else medical schools risk generating a false sense of individual and institutional progress.

The burden of grief: A scoping review of nurses' and physicians' experiences throughout the COVID-19 pandemic.

Coping with loss is an unfortunate reality faced by healthcare professionals, and the COVID-19 pandemic exacerbated this challenge for those who worked on the frontlines. Our scoping review aimed to comprehensively map the existing literature pertaining to the experiences of grief among nurses and physicians in the context of the pandemic. Six bibliographic databases were searched in 2022, and a targeted search of gray literature and citation chasing was also performed. After screening a total of 2920 records, we included 173 evidence sources in this review. Data was both analyzed descriptively (e.g., frequency counts and percentages) and using a qualitative content analysis approach. Our findings illuminate the myriad losses experienced by nurses and physicians throughout the pandemic. While the literature portrays the coping mechanisms healthcare professionals have developed personally, there is a pronounced need for increased institutional support to alleviate the burdens they carry.

Front row seat: The role MMI assessors play in widening access to medical school.

BACKGROUND: While many medical schools utilize the Multiple Mini-Interview (MMI) to help select a diverse student body, we know little about MMI assessors' roles. Do MMI assessors carry unique insights on widening access (WA) to medical school? Herein we discuss the hidden expertise and insights that assessors contribute to the conversation around WA. METHODS: Ten MMI assessors (1-10 years' experience) participated in semi-structured interviews exploring factors influencing equitable medical school recruitment. Given their thoughtfulness during initial interviews, we invited them for follow-up interviews to gain further insight into their perceived role in WA. Fourteen interviews were conducted and analyzed using a thematic analysis approach. RESULTS: Assessors expressed concerns with diversity in medicine; dissatisfaction with the status quo fueled their contributions to the selection process. Assessors advocated for greater diversity among the assessor pool, citing benefits for all students, not only those from underrepresented groups. They noted that good intentions were not enough and that medical schools can do more to include underrepresented groups' perspectives in the admissions process. CONCLUSION: Our analysis reveals that MMI assessors are committed to WA and make thoughtful contributions to the selection process. A medical school selection process, inclusive of assessors' expertise is an important step in WA.

Case-Informed Learning in Medical Education: A Call for Ontological Fidelity.

Case-informed learning is an umbrella term we use to classify pedagogical approaches that use text-based cases for learning. Examples include Problem-Based, Case-Based, and Team-Based approaches, amongst others. We contend that the cases at the heart of case-informed learning are philosophical artefacts that reveal traditional positivist orientations of medical education and medicine, more broadly, through their centering scientific knowledge and objective fact. This positivist orientation, however, leads to an absence of the human experience of medicine in most cases. One of the rationales for using cases is that they allow for learning in context, representing aspects of real-life medical practice in controlled environments. Cases are, therefore, a form of simulation. Yet issues of fidelity, widely discussed in the broader simulation literature, have yet to enter discussions of case-informed learning. We propose the concept of ontological fidelity as a way to approach ontological questions (i.e., questions regarding what we assume to be real), so that they might centre narrative and experiential elements of medicine. Ontological fidelity can help medical educators grapple with what information should be included in a case by encouraging an exploration of the philosophical questions: What is real? Which (and whose) reality do we want to simulate through cases? What are the essential elements of a case that make it feel real? What is the clinical story we want to reproduce in case format? In this Eye-Opener, we explore what it would mean to create cases from a position of ontological fidelity and provide suggestions for how to do this in everyday medical education.

Navigating the burden of proof and responsibility: A narrative inquiry into Indigenous medical learners' experiences.

INTRODUCTION: Many medical schools have well-established admission pathways and programming to support Indigenous medical workforce development. Ideally, these efforts should contribute to attracting highly qualified Indigenous applicants which, in turn, may improve accessible, quality care for Indigenous people. However, it is difficult to evolve and tailor these approaches without a situated understanding of Indigenous learners' experiences. In this paper, we focus on the Canadian context, sharing Indigenous learners' stories about their journey towards and throughout medical training. METHODS: The conceptual underpinnings of narrative inquiry and key principles from Indigenous methodologies were drawn upon throughout both data collection and analysis. Participants were Indigenous learners (medical students and residents) and a recently graduated physician (n = 5) from one Canadian medical school. Both spoken (formal recorded interviews) and visual (photographs) texts were used to make meaning of participants' experiences. RESULTS: Participants' experiences during medical training showed a striking resemblance at three points in their transition to, and progression through, medical education: preparing for and applying to medical school, completing undergraduate medical training and determining specialty choice. Participants' stories revealed a tug-of-war between their identities as an Indigenous person and as a medical trainee, with these tensions sometimes compromising their perceived sense of belonging within both Indigenous and academic circles, creating, at times, a heavy burden to shoulder. CONCLUSION: Meaningful representation of Indigenous people in the medical workforce is about more than training additional health care providers; it requires understanding Indigenous learners and recently graduated physicians' experiences as they enter and navigate the medical profession. By amplifying their voices, we stand to gain a more holistic representation of the factors that contribute to and potentially impede the recruitment and retention of Indigenous people into the medical profession.

Expanding the advocacy lens: using photo-elicitation to capture patients' and physicians' perspectives about health advocacy.

Heath advocacy (HA) remains a difficult competency to train and assess, in part because practicing physicians and learners carry uncertainty about what HA means and we are missing patients' perspectives about the role HA plays in their care. Visual methods are useful tools for exploring nebulous topics in health professions education; using these participatory approaches with physicians and patients might counteract the identified training challenges around HA and more importantly, remedy the exclusion of patient perspectives. In this paper we share the verbal and visual reflections of patients and physicians regarding their conceptualizations of, and engagement in 'everyday' advocacy. In doing so, we reveal some of HA's hidden dimensions and what their images uncovered about the role of advocacy in patient care. Constructivist grounded theory guided data collection and analysis. Data was collected through semi-structured interviews and photo-elicitation, a visual research method that uses participant generated photographs to elicit participants knowledge and experiences around a particular topic. We invited patients living with chronic health conditions (n = 10) and physicians from diverse medical and surgical specialties (n = 14) to self-select photographs representing their experiences navigating HA in their personal and professional lives. Both groups found taking photographs useful for revealing the nuanced and circumstantial factors that either enabled or challenged their engagement in HA. While patients' photos highlighted their embodiment of HA, physicians' photos depicted HA as something quite elusive or as a complicated and daunting task. Photo-elicitation was a powerful tool in eliciting a diversity of perspectives that exist around the HA role and the work advocates perform; training programs might consider using visuals to augment teaching for this challenging competency.

'Click, I Guess I'm Done': Applicants' and Assessors' Experiences Transitioning to a Virtual Multiple Mini Interview Format.

Introduction: During the COVID-19 pandemic, medical schools were forced to suspend in-person interviews and transition to a virtual Multiple Mini Interview (vMMI) format. MMIs typically comprise multiple short assessments overseen by assessors, with the aim of measuring a wide range of non-cognitive competencies. The adaptation to vMMI required medical schools to make swift changes to their MMI structure and delivery. In this paper, we focus on two specific groups greatly impacted by the decision to transition to vMMIs: medical school applicants and MMI assessors. Methods: We conducted an interpretive qualitative study to explore medical school applicants' and assessors' experiences transitioning to an asynchronous vMMI format. Ten assessors and five medical students from one Canadian medical school participated in semi-structured interviews. Data was analyzed using a thematic analysis framework. Results: Both applicants and assessors shared a mutual feeling of longing and nostalgia for an interview experience that, due to the pandemic, was understandably adapted. The most obvious forms of loss experienced - albeit in different ways - were: 1) human connection and 2) missed opportunity. Applicants and assessors described several factors that amplified their grief/loss response. These were: 1) resource availability, 2) technological concerns, and 3) the virtual interview environment. Discussion: While virtual interviewing has obvious advantages, we cannot overlook that asynchronous vMMIs do not lend themselves to the same caliber of interaction and camaraderie as experienced in in-person interviews. We outline several recommendations medical schools can implement to enhance the vMMI experience for applicants and assessors.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees.

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

Seven ways to get a grip on preparing for and executing an inclusive virtual multiple mini interview.

COVID-19 restrictions have prompted many medical schools to shift to virtual interview methods for medical school applicant selection. While extensive reflection has been documented around both the process and benefits of transitioning to a virtual Multiple Mini Interview (V-MMI) format, less attention has been given to examining the unintended consequences of this adaptation on increasing representation from underrepresented groups. In this Black Ice article, we consider the equity implications of taking a virtual approach to conducting MMIs and present some practical tips to ensure medical schools are giving attention to and addressing equity issues that may affect applicant and assessor engagement and success. The following seven recommendations include actionable steps medical schools can take immediately to optimize the interview process. This guide can be adapted to residency matching services and other health professions education programs that utilize the MMI.

Les restrictions liées à la COVID-19 ont incité de nombreuses facultés de médecine à recourir à l'entrevue virtuelle pour la sélection des candidats. Malgré la réflexion approfondie qui a été menée et documentée sur le processus de transition et les avantages qu'offre le format virtuel des mini-entrevues multiples (V-MMI), les conséquences involontaires de cette adaptation sur la représentation de populations sous-représentées ont été négligées. Dans cet article, nous explorons le terrain glissant des conséquences de la MMI virtuelle sur l'équité et nous présentons quelques conseils pratiques pour appeler l'attention et l'action des facultés de médecine sur ces enjeux qui peuvent affecter la capacité du candidat et de l'évaluateur à interagir, ainsi que l'efficacité de l'entretien. Les sept recommandations comprennent des mesures concrètes que les facultés de médecine peuvent prendre immédiatement pour optimiser le processus d'entrevue. Ce guide peut être adapté au service de jumelage des résidents et aux autres programmes de formation des professions de la santé qui utilisent la MMI.

From struggle to opportunity: Reimagining medical education in a pandemic era.

The COVID-19 pandemic has disrupted the international medical education community in unprecedented ways. The restrictions imposed to control the spread of the virus have upended our routines and forced us to reimagine our work structures, educational programming and delivery of patient care in ways that will likely continue to change how we live and work for the foreseeable future. Yet, despite these interruptions, the pandemic has additionally sparked a transformative impulse in some to actively engage in critical introspection around the future of their work, compelling us to consider what changes could (and perhaps should) occur after the pandemic is over. Drawing on key concepts associated with scholar Paulo Freire's critical pedagogy, this paper serves as a call to action, illuminating the critical imaginings that have come out of this collective moment of struggle and instability, suggesting that we can perhaps create a more just, compassionate world even in the wake of extraordinary hardship.

A phenomenological exploration of the impact of COVID-19 on the medical education community.

INTRODUCTION: The COVID-19 pandemic has caused unprecedented stress to the medical education community, potentially worsening problems like burnout and work-life imbalance that its members have long been grappling with. However, the collective struggle sparked by the pandemic could generate the critical reflection necessary for transforming professional values and practices for the better. In this hermeneutic phenomenological study, we explore how the community is adapting-and even reconceptualising-their personal and professional roles amidst the COVID-19 crisis. METHOD: Between April and October 2020, we conducted 27 (17F, 10M) semi-structured interviews with medical trainees (8), physicians (8), graduate students (3) and PhD scientists (8) working in medical education in Canada, the United States and Switzerland. Data analysis involved a variety of strategies, including coding for van Manen's four lifeworld existentials, reflexive writing and multiple team meetings. RESULTS: Participants experienced grief related to the loss of long-established personal and professional structures and boundaries, relationships and plans for the future. However, experiences of grief were often conflicting. Some participants also experienced moments of relief, perceiving some losses as metaphorical permissions slips to slow down and focus on their well-being. In turn, many reflected on the opportunity they were being offered to re-imagine the nature of their work. DISCUSSION: Participants' experiences with grief, relief and opportunity resonate with Ratcliffe's account of grief as a process of relearning the world after a significant loss. The dismantling of prior life structures and possibilities incited in participants critical reflection on the nature of the medical education community's professional practices. Participants demonstrated their desire for more flexibility and autonomy in the workplace and a re-adjustment of the values and expectations inherent to their profession. On both individual and systems levels, the community must ensure that long-standing calls for wellness and work-life integration are realised-and persist-after the pandemic is over.

Navigating the uncertainty of health advocacy teaching and evaluation from the trainee's perspective.

BACKGROUND: There may be no competency more shrouded in uncertainty than health advocacy (HA), raising questions about the robustness of advocacy training in postgraduate medical education. By understanding how programs currently train HA, we can identify whether trainees' learning needs are being met. METHODS: From 2017 to 2019, we reviewed curricular documents across nine direct-entry specialties at all Ontario medical schools, comparing content for the HA and communicator roles to delineate role-specific challenges. We then conducted semi-structured interviews with trainees (n = 9) and faculty (n = 6) to review findings and discuss their impact. Data were analyzed using thematic content analysis. RESULTS: Curricular documents revealed vague objectives and ill-defined modes of assessment for both intrinsic roles. This uncertainty was perceived as more problematic for HA, in part because HA seemed both undervalued in, and disconnected from, clinical learning. Trainees felt that the onus was on them to figure out how to develop and demonstrate HA competence, causing many to turn their learning attention elsewhere. DISCUSSION: Lack of curricular focus seems to create the perception that advocacy isn't valuable, deterring trainees-even those keen to become competent advocates-from developing HA skills. Such ambivalence may have troubling downstream effects for both patient care and trainees' professional development.

Exploring patients' and physicians' perspectives about competent health advocacy.

INTRODUCTION: Many residency programmes struggle to demonstrate how they prepare trainees to become competent health advocates. To meaningfully teach and assess it, we first need to understand what 'competent' health advocacy (HA) is and what competently enacting it requires. Attempts at clarifying HA have largely centred around the perspectives of consultant physicians and trainees. Without patients' perspectives, we risk training learners to advocate in ways that may be misaligned with patients' needs and goals. Therefore, the purpose of our research was to generate a multi-perspective understanding about the meaning of competence for the HA role. METHODS: We used constructivist grounded theory to explore patients' and physicians' perspectives about competent health advocacy. Data were collected using photo elicitation; patients (n = 10) and physicians (n = 14) took photographs depicting health advocacy that were used to inform semi-structured interviews. Themes were identified using constant comparative analysis. RESULTS: Physician participants associated HA with disruption or political activism, suggesting that competence hinged on medical and systems expertise, a conducive learning environment, and personal and professional characteristics including experience, status and political savvy. Patient participants, however, equated physician advocacy with patient centredness, perceiving that competent HAs are empathetic and attentive listeners. In contrast to patients, few physicians identified as advocates, raising questions about their ability to train or to thoughtfully assess learners' abilities. CONCLUSION: Few participants perceived HA as a fundamental physician role-at least not as it is currently defined in curricular frameworks. Misperceptions that HA is primarily disruptive may be the root cause of the HA problem; solving it may rely on focusing training on bolstering skills like empathy and listening not typically associated with the HA role. Since there may be no competency where the patient voice is more critical, we need to explore opportunities for patients to facilitate learning for the HA role.

"Doing it Right" Overnight: a Multi-perspective Qualitative Study Exploring Senior Medical Resident Overnight Call.

BACKGROUND: Competency-based medical education (CBME) requires the development of workplace-based assessment tools that are grounded in authentic clinical work. Developing such tools, however, requires a deep understanding of the underlying facets of the competencies being assessed. Gaining this understanding remains challenging in contexts where performance is not readily visible to supervisors such as the senior medical resident (SMR) on-call role in internal medicine. OBJECTIVE: This study draws on the perspectives of healthcare professionals with whom the SMR interacts with overnight to generate insights into the different components of on-call SMR practice and the range of ways SMRs effectively and less effectively enact these. APPROACH: We used a constructivist grounded theory (CGT) approach to examine variation in how on-call SMRs carry out their role overnight. PARTICIPANTS: Six medical students, five junior residents, five internal medicine attending physicians, five emergency physicians, and three emergency nurses conducted observations of their on-call interactions with SMRs. Participants were then interviewed and asked to elaborate on their observations as well as provide comparative reflections on the practices of past SMRs they worked with. KEY RESULTS: Strong collaboration and organizational skills were identified as critical components to effectively being the on-call SMR. Perceived weaker SMRs, while potentially also having issues with clinical skills, stood out more when they could not effectively manage the realities of collaboration in a busy workplace. CONCLUSION: What consistently differentiated a perceived effective SMR from a less effective SMR was someone who was equipped to manage the realities of interprofessional collaboration in a busy workplace. Our study invites medical educators to consider what residents, particularly those in more complex roles, need to receive feedback on to support their development as physicians. It is our intention that the findings be used to inform the ways programs approach teaching, assessment, and the provision of feedback.

Are we generating more assessments without added value? Surgical trainees' perceptions of and receptiveness to cross-specialty assessment.

INTRODUCTION: Competency-based medical education (CBME) hinges on robust assessment. However, integrating regular workplace-based assessment within demanding and sometimes chaotic clinical environments remains challenging. Many faculty lack assessment expertise, and some programs lack the infrastructure and faculty numbers to fulfill CBME's mandate. Recognizing this, we designed and implemented an assessment innovation that trains and deploys a cadre of faculty to assess in specialties outside their own. Specifically, we explored trainees' perceptions of and receptiveness to this novel assessment approach. METHODS: Within Western University's Surgical Foundations program, 27 PGY­1 trainees were formatively assessed by trained non-surgeons on a basic laparoscopic surgical skill. These assessments did not impact trainees' progression. Four focus groups were conducted to gauge residents' sentiments about the experience of cross-specialty assessment. Data were then analyzed using a thematic analysis approach. RESULTS: While a few trainees found the experience motivating, more often trainees questioned the feedback they received and the practicality of this assessment approach to advance their procedural skill acquisition. What trainees wanted were strategies for improvement, not merely an assessment of performance. DISCUSSION: Trainees' trepidation at the idea of using outside assessors to meet increased assessment demands appeared grounded in their expectations for assessment. What trainees appeared to desire was a coach-someone who could break their performance into its critical individual components-as opposed to an assessor whose role was limited to scoring their performance. Understanding trainees' receptivity to new assessment approaches is crucial; otherwise training programs run the risk of generating more assessments without added value.

"The storm has arrived": the impact of SARS-CoV-2 on medical students.

In a few weeks, the global community has witnessed, and for some of us experienced first-hand, the human costs of the COVID-19 pandemic. There is incredible variability in how countries are choosing to thwart the disease's outbreak, sparking intense discussions around what it means to teach and learn in the era of COVID-19, and more specifically, the role medical students play in the midst of the pandemic. A multi-national and multi-institutional group made up of a dedicated medical student from Austria, passionate clinicians and educators from Switzerland, and a PhD scientist involved in Medical Education from Canada, have assembled to summarize the ingenious ways medical students around the world are contributing to emergency efforts. They argue that such efforts change COVID-19 from a "disruption" to medical students learning to something more tangible, more important, allowing students to become stakeholders in the expansion and delivery of healthcare.

"You Want Me to Assess What?": Faculty Perceptions of Assessing Residents From Outside Their Specialty.

PROBLEM: Competency-based medical education (CBME) demands that residents be directly observed performing clinical tasks; however, many faculty lack assessment expertise, and some programs lack resources and faculty numbers to fulfill CBME's mandate. To maximize limited faculty resources, the authors explored training and deploying faculty to assess residents in specialties outside their own. APPROACH: In spring 2017, 10 MD and 2 PhD assessors at a medium-sized medical school in Ontario, Canada, participated in a 4-hour training session, which focused on providing formative assessments of patient handover, a core competency of medical practice. Assessors were deployed to 2 clinical settings outside their own specialty-critical care and pediatrics-each completing 11 to 26 assessments of residents delivering patient handover. Assessors were subsequently interviewed regarding their experiences. OUTCOMES: While assessors felt able to judge handover performance outside their specialty, their sense of comfort varied with their own prior experiences in the given settings. Lack of familiarity with the process of handover in a specific setting directly influenced assessors' perceptions of their own credibility. Although assessors identified the potential benefits of cross-specialty assessment, they also cited challenges to sustaining this approach. NEXT STEPS: Findings indicate a possible "contextual threshold" for cross-specialty assessment: tasks with high context specificity might not be suitable for cross-specialty assessment. Introducing higher-fidelity simulation into the training protocol and ensuring faculty members are remunerated for their time are necessary to establish future opportunities for shared assessment resources across training programs.

Recognising the importance of informal communication events in improving collaborative care.

BACKGROUND: While the concept of collaboration is highly touted in the literature, most descriptions of effective collaboration highlight formal collaborative events; largely ignored are the informal collaborative events and none focusing on the frequent, 'seemingly' by chance communication events that arise and their role in supporting patient safety and quality care. OBJECTIVE: To identify the types of informal communication events that exist in the inpatient setting and better understand the barriers contributing to their necessity. METHODS: We undertook a constructivist grounded theory study in an inpatient internal medicine teaching unit in Ontario, Canada. Interview and observational data were collected across two phases; in total, 56 participants were consented for the study. Data collection and analysis occurred iteratively; themes were identified using constant comparison methods. RESULTS: Several types of informal communication events were identified and appeared valuable in three ways: (1) providing a better sense of a patient's baseline function in comparison to their current function; (2) gaining a more holistic understanding of the patient's needs; and (3) generating better insight into a patient's wishes and goals of care. Participants identified a number of organisational and communication challenges leading to the need for informal communication events. These included: scheduling, competing demands and the spatial and temporal organisation of the ward. As a result, nursing staff, allied health professionals and caregivers had to develop strategies for interacting with the physician team. CONCLUSION: We highlight the importance of informal communication in supporting patient care and the gaps in the system contributing to their necessity. Changes at the system level are needed to ensure we are not leaving important collaborative opportunities to chance alone.