Conceptualising and Teaching Biomedical Uncertainty to Medical Students: an Exploratory Qualitative Study.

Introduction: Certainty/uncertainty in medicine is a topic of popular debate. This study aims to understand how biomedical uncertainty is conceptualised by academic medical educators and how it is taught in a medical school in the UK. Methods: This is an exploratory qualitative study grounded in ethnographic principles. This study is based on 10 observations of teaching sessions and seven semi-structured qualitative interviews with medical educators from various biomedical disciplines in a UK medical school. The data set was analysed via a thematic analysis. Results: Four main themes were identified after analysis: (1) ubiquity of biomedical uncertainty, (2) constraints to teaching biomedical uncertainty, (3) the 'medic filter' and (4) fluid distinction: core versus additional knowledge. While medical educators had differing understandings of how biomedical uncertainty is articulated in their disciplines, its presence was ubiquitous. This ubiquity did not translate into teaching due to time constraints and assessment strategies. The 'medic filter' emerged as a strategy that educators employed to decide what to include in their teaching. They made distinctions between core and additional knowledge which were defined in varied ways across disciplines. Additional knowledge often encapsulated biomedical uncertainty. Discussion: Even though the perspective that knowledge is socially constructed is not novel in medical education, it is neither universally valued nor universally applied. Moving beyond situativity theories and into broader debates in social sciences provides new opportunities to discuss the nature of scientific knowledge in medical education. We invite a move away from situated learning to situated knowledge.

"I Do Not Have to Hurt My Body Anymore": Reproductive Chronicity and Sterilization as Ambivalent Care in Rural North India.

Drawing on 18 months of ethnographic fieldwork in rural Rajasthan, India, I examine women's narratives of chronic reproductive suffering and the practices they employed to relieve it. Cumulative effects of adverse and ordinary reproductive events and exhaustion from caregiving were often seen as reproductive suffering, while sterilization emerged as an act of care toward women's ever-weakening bodies. Sterilization has been an integral part of the often coercive, incentive- and target-driven population control program in India. Rural women, however, described sterilization not as a form of violence but as an act of care, despite its ambivalence. In the context of reproductive chronicity-a persistent reproductive suffering recurring alongside reproductive events, available care options, relations within which these options are located, and structural conditions that shape women's lives-care and suffering are intimately and ambiguously intertwined.

"Everything in India Happens by Jugaad": Dai-mas in Institutions in Rural Rajasthan.

Since the introduction of a scheme promoting institutional deliveries in India, dai-mas (traditional midwives) have not become obsolete, but remain integral to institutional caregiving in rural areas in ways that are not always recognized. Based on ethnographic fieldwork in rural Rajasthan, I discuss two institutional contexts in which dai-mas were encountered - traditional midwife training event and hospital births. By examining how dai-mas' authoritative knowledge is reconfigured within institutions, I suggest that the polysemic Hindi term jugaad - a phrase describing the kinds of improvisation required in resource-poor settings - captures different aspects of dai-mas' relationships with and within institutions and the state of maternal caregiving in rural India.

Exploring differences in individual and group judgements in standard setting.

CONTEXT: Standard setting is critically important to assessment decisions in medical education. Recent research has demonstrated variations between medical schools in the standards set for shared items. Despite the centrality of judgement to criterion-referenced standard setting methods, little is known about the individual or group processes that underpin them. This study aimed to explore the operation and interaction of these processes in order to illuminate potential sources of variability. METHODS: Using qualitative research, we purposively sampled across UK medical schools that set a low, medium or high standard on nationally shared items, collecting data by observation of graduation-level standard-setting meetings and semi-structured interviews with standard-setting judges. Data were analysed using thematic analysis based on the principles of grounded theory. RESULTS: Standard setting occurred through the complex interaction of institutional context, judges' individual perspectives and group interactions. Schools' procedures, panel members and atmosphere produced unique contexts. Individual judges formed varied understandings of the clinical and technical features of each question, relating these to their differing (sometimes contradictory) conceptions of minimally competent students, by balancing information and making suppositions. Conceptions of minimal competence variously comprised: limited attendance; limited knowledge; poor knowledge application; emotional responses to questions; 'test-savviness', or a strategic focus on safety. Judges experienced tensions trying to situate these abstract conceptions in reality, revealing uncertainty. Groups constructively revised scores through debate, sharing information and often constructing detailed clinical representations of cases. Groups frequently displayed conformity, illustrating a belief that outlying judges were likely to be incorrect. Less frequently, judges resisted change, using emphatic language, bargaining or, rarely, 'polarisation' to influence colleagues. CONCLUSIONS: Despite careful conduct through well-established procedures, standard setting is judgementally complex and involves uncertainty. Understanding whether or how these varied processes produce the previously observed variations in outcomes may offer routes to enhance equivalence of criterion-referenced standards.