A Scoping Review of Interprofessional Simulation-Based Team Training Programs.

SUMMARY STATEMENT: Interprofessional simulation-based team training (ISBTT) is promoted as a strategy to improve collaboration in healthcare, and the literature documents benefits on teamwork and patient safety. Teamwork training in healthcare is traditionally grounded in crisis resource management (CRM), but it is less clear whether ISBTT programs explicitly take the interprofessional context into account, with complex team dynamics related to hierarchy and power. This scoping review examined key aspects of published ISBTT programs including (1) underlying theoretical frameworks, (2) design features that support interprofessional learning, and (3) reported behavioral outcomes. Of 4854 titles identified, 58 articles met inclusion criteria. Most programs were based on CRM and related frameworks and measured CRM outcomes. Only 12 articles framed ISBTT as interprofessional education and none measured all interprofessional competencies. The ISBTT programs may be augmented by integrating theoretical concepts related to power and intergroup relations in their design to empower participants to navigate complex interprofessional dynamics.

"It's All About the Trust And Building A Foundation:" Evaluation of a Longitudinal Medical Student Coaching Program.

Coaching is increasingly implemented in medical education to support learners' growth, learning, and wellbeing. Data demonstrating the impact of longitudinal coaching programs are needed.We developed and evaluated a comprehensive longitudinal medical student coaching program designed to achieve three aims for students: fostering personal and professional development, advancing physician skills with a growth mindset, and promoting student wellbeing and belonging within an inclusive learning community. We also sought to advance coaches' development as faculty through satisfying education roles with structured training. Students meet with coaches weekly for the first 17 months of medical school for patient care and health systems skills learning, and at least twice yearly throughout the remainder of medical school for individual progress and planning meetings and small-group discussions about professional identity. Using the developmental evaluation framework, we iteratively evaluated the program over the first five years of implementation with multiple quantitative and qualitative measures of students' and coaches' experiences related to the three aims.The University of California, San Francisco, School of Medicine, developed a longitudinal coaching program in 2016 for medical students alongside reform of the four-year curriculum. The coaching program addressed unmet student needs for a longitudinal, non-evaluative relationship with a coach to support their development, shape their approach to learning, and promote belonging and community.In surveys and focus groups, students reported high satisfaction with coaching in measures of the three program aims. They appreciated coaches' availability and guidance for the range of academic, personal, career, and other questions they had throughout medical school. Students endorsed the value of a longitudinal relationship and coaches' ability to meet their changing needs over time. Students rated coaches' teaching of foundational clinical skills highly. Students observed coaches learning some clinical skills with them - skills outside a coach's daily practice. Students also raised some concerns about variability among coaches. Attention to wellbeing and belonging to a learning community were program highlights for students. Coaches benefited from relationships with students and other coaches and welcomed the professional development to equip them to support all student needs.Students perceive that a comprehensive medical student coaching program can achieve aims to promote their development and provide support. Within a non-evaluative longitudinal coach relationship, students build skills in driving their own learning and improvement. Coaches experience a satisfying yet challenging role. Ongoing faculty development within a coach community and funding for the role seem essential for coaches to fulfill their responsibilities.

Exploring the role of power during debriefing of interprofessional simulations.

Interprofessional simulation aims to improve teamwork and patient care by bringing participants from multiple professions together to practice simulated patient care scenarios. Yet, power dynamics may influence interprofessional learning during simulation, which typically occurs during the debriefing. This issue has received limited attention to date but may explain why communication breakdowns and conflicts among healthcare teams persist despite widespread adoption of interprofessional simulation. This study explores the role of power during interprofessional simulation debriefings. We collected data through observations of seven interprofessional simulation sessions and debriefings, four focus groups with simulation participants, and four interviews with simulation facilitators. We identified ways in which power dynamics influenced discussions during debriefing and sometimes limited participants' willingness to share feedback and speak up. We also found that issues related to power that arose during interprofessional simulations often went unacknowledged during the debriefing, leaving healthcare professionals unprepared to navigate power discrepancies with other members of healthcare teams in practice. Given that the goal of interprofessional simulation is to allow professionals to learn together about each other, explicitly addressing power in debriefing after interprofessional simulation may enhance learning.

Publishing your scholarship: a survey of pearls from top reviewers.

Experts have described ways to improve peer review quality. Perspectives from expert reviewers are largely absent in the health professions education literature. To gather guidance from expert reviewers, to aid authors striving to publish and reviewers aiming to perform their task effectively. This study surveyed the Journal of Graduate Medical Education (JGME) 'Top Reviewers' from 2017, 2018, and 2019. 'Top Reviewers' perform four or more reviews per year, with high average ratings. Top reviewers were sent an 11-item survey in February 2020. The survey included three demographic questions and eight open-ended, free-text questions about the concepts reviewers most often target in their reviews. We calculated descriptive statistics and performed a thematic analysis of open-ended responses. Of 62 eligible top reviewers, 44 (71%) responded to the survey. Only eight (18.2%) and seven (15.9%) respondents reported having 'stock phrases' or a reviewer template used for reviewer feedback to authors, respectively. The what (research question, methods), how (presentation, writing), and why (relevance, impact) were the resulting themes summarizing how reviewers categorized and responded to common problems. For 'really good papers' reviewers found the what acceptable and focused on how and why. For 'really bad' papers, reviewers focused on big picture feedback, such as the value of the study. Top reviewers from a single health professions education journal appear to have similar approaches to conducting reviews. While most do not use stock phrases or templates, they share similar strategies to differentiate 'good' vs. 'bad' papers through the what, why, and how of a manuscript.

Towards equitable learning environments for medical education: Bias and the intersection of social identities.

CONTEXT: Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences. METHODS: This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities. RESULTS: Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management. CONCLUSIONS: Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

A Vicious Cycle of Bias: Residents' Perceptions of Leadership in Health Care.

PURPOSE: Despite growing interest in shared leadership models, autocratic physician leadership remains the norm in health care. Stereotype and bias limit leadership by members of other professions. Furthermore, traditional views of effective clinical leadership emphasize agentic behaviors associated with male gender. To shift the prototypical concept of a leader from a male physician to a more inclusive prototype, a better understanding of prototype formation is needed. This study examines leader prototypes and their development among resident physicians through the lens of leadership categorization theory. METHOD: One researcher conducted semistructured interviews with anesthesia and internal medicine residents at a single institution, asking participants to describe their ideal team leader and comment on the video-recorded performance of either a male or female nurse practitioner (NP) leading a simulated resuscitation. Interview questions explored participants' perceptions of NPs as team leaders and how these perceptions developed. The researchers conducted deductive analysis to examine leadership prototypes and prototype formation, and inductive analysis to derive additional themes. RESULTS: The majority of residents described a male physician as the ideal resuscitation team leader. Exposure to male physician leaders, and lack of exposure to NP leaders, contributed to this prototype formation. Residents described a vicious cycle in which bias against female and NP leaders diminished acceptance of their leadership by team members, resulting in decreased confidence and performance, further aggravating bias. CONCLUSIONS: These results provide suggestions for interventions that can help shift the leadership prototype in health care and promote shared leadership models. These include increasing exposure to different professionals of either gender in leadership roles and increased representation in educational materials, education about effective leadership strategies to create awareness of the benefits of shared leadership, and reflection during team training to increase awareness of bias and the backlash effect faced by individuals whose behaviors counter established stereotypes.

Accessible and Adaptable Faculty Development to Support Curriculum Reform in Medical Education.

Contemporary curricular reform in medical education focuses on areas that current physician-educators were likely not exposed to during medical school, such as interprofessional teamwork; informatics; health care systems improvement; and diversity, equity, and inclusion. Thus, faculty may not be ready to support the planned curricular reform without adequate faculty development to acquire the necessary knowledge and skills. In an era with increasing demands on faculty, new approaches that are flexible and adaptable are needed. The University of California, San Francisco, School of Medicine implemented a new curriculum in 2016, which constituted a major curricular overhaul necessitating extensive faculty development. Based on this experience, the author proposes 8 guiding principles for faculty development around curricular reform: (1) create a blueprint to inform design and implementation of faculty development activities; (2) build on existing resources, networks, and communities; (3) target different needs and competency levels for different groups of faculty; (4) encourage cocreation in the workplace; (5) promote collaboration between content experts and faculty developers; (6) tap into faculty's intrinsic motivation for professional development; (7) develop curriculum leaders and faculty developers; and (8) evaluate for continuous improvement. Each of these principles is illustrated with examples, and when available, supported by references to relevant literature. Considering the current wave of curricular reform, both at the undergraduate and graduate levels, these principles can be useful for other institutions.

E-ASSESS: Creating an EPA Assessment Tool for Structured Simulated Emergency Scenarios.

BACKGROUND: The entrustable professional activity (EPA) assessment framework allows supervisors to assign entrustment levels to physician trainees for specific activities. Limited opportunity for direct observation of trainees hampers entrustment decisions, in particular for infrequently performed activities. Simulation allows for direct observation, so tools to assess performance of EPAs in simulation could potentially provide additional data to complement clinical assessments. OBJECTIVE: We developed and collected validity evidence for a simulation-based tool grounded in the EPA framework. METHODS: We developed E-ASSESS (EPA Assessment for Structured Simulated Emergency ScenarioS) to assess performance in 2 EPAs among pediatric residents participating in simulation-based team training in 2017-2018. We collected validity data, applying Messick's unitary view. Three raters used E-ASSESS to assign entrustment levels based on performance in simulation. We compared those ratings to entrustment levels assigned by clinical supervisors (different from the study raters) for the same residents on a separate tool designed for clinical practice. We calculated intraclass correlation (ICC) for each tool and Pearson correlation coefficients to compare ratings between tools. RESULTS: Twenty-eight residents participated in the study. The ICC between the 3 raters for entrustment ratings on E-ASSESS ranged from 0.65 to 0.77, while ICC among raters of the clinical tool were 0.59 and 0.57. We found no significant correlations between E-ASSESS ratings and clinical practice ratings for either EPA (r = -0.35 and 0.38, P > .05). CONCLUSIONS: Assessment following an EPA framework in the simulation context may be useful to provide data points to inform entrustment decisions as part of resident assessment.

Twelve tips for assessing medical knowledge with open-ended questions: Designing constructed response examinations in medical education.

Medical knowledge examinations employing open-ended (constructed response) items can be useful to assess medical students' factual and conceptual understanding. Modern day curricula that emphasize active learning in small groups and other interactive formats lend themselves to an assessment format that prompts students to share conceptual understanding, explain, and elaborate. The open-ended question examination format can provide faculty with insights into learners' abilities to apply information to clinical or scientific problems, and reveal learners' misunderstandings about essential content. To implement formative or summative assessments with open-ended questions in a rigorous manner, educators must design systems for exam creation and scoring. This includes systems for constructing exam blueprints, items and scoring rubrics, and procedures for scoring and standard setting. Information gained through review of students' responses can guide future educational sessions and curricular changes in a cycle of continuous improvement.

"A Friendly Place to Grow as an Educator": A Qualitative Study of Community and Relationships Among Medical Student Coaches.

PURPOSE: The rise of coaching programs in medical education sparks questions about ways to support physician coaches in learning new educational practices specific to coaching. How coaches learn from one another is of particular interest considering the potential value of social learning. Using communities of practice as a conceptual framework, the authors examine the sense of community and relationships among coaches in a new medical student coaching program, the value of this community, and the facilitators and barriers influencing community development. METHOD: In this qualitative study, investigators conducted 34 interviews with physician coaches at 1 institution over 2 years (2017-2018) and observed 36 coach meetings. Investigators analyzed interview transcripts using thematic analysis and used observation field notes for context and refinement of themes. RESULTS: Coaches described a sense of community based on regular interactions; shared commitment to medical education; and new roles with similar experiences, joys, and challenges. They valued the sense of camaraderie and support, learning from one another, and opportunities for professional growth that strengthened their identities as educators and enhanced job satisfaction. Facilitators of community included regular meetings, leadership and administrative support, and informal opportunities to interact outside of meetings. Barriers included time constraints and geographic challenges for coaches at off-site locations. CONCLUSIONS: The sense of community among coaches was a valued and beneficial part of their coaching experience. Coaches' interactions and relationships promoted skill acquisition, knowledge transfer, professional development, and career satisfaction. Thus, incorporating support for social learning in coaching programs promotes coach faculty development.

Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters.

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains. DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017. SETTING: Multicenter study conducted in 33 PICUs across eight countries. SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation. INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions. MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008). CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach.

PROBLEM: Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners. APPROACH: The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS. OUTCOMES: Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS. NEXT STEPS: Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.

Effect of Professional Background and Gender on Residents' Perceptions of Leadership.

PURPOSE: To examine the impact of professional background and gender of a resuscitation team leader on residents' perceptions of leadership skills. METHOD: The authors video-recorded a scripted, simulated resuscitation scenario twice, with either a male or a female team leader. They copied each video and labeled the leader as physician (MD) or nurse practitioner (NP), creating 4 conditions: female NP, female MD, male NP, or male MD. The authors recruited resident participants from 5 specialties at 4 institutions; they randomly assigned residents to view one version of the video and rate the team leader's performance using the Ottawa Crisis Resource Management Global Rating Scale (Ottawa CRM) in an online survey. The authors conducted 2-way ANOVA to examine interactions between team leader gender and profession on Ottawa CRM ratings. RESULTS: One hundred sixty residents responded (89 females, 71 males). A statistically significant main effect of team leader gender on residents' ratings was found in 2 of the 6 Ottawa CRM domains, leadership (F1,156 = 6.97, P = .009) and communication skills (F1,156 = 8.53, P = .004), due to lower ratings for female than male leaders (5.29 ± 0.95 vs 5.74 ± 1.17; 5.05 ± 1.20 vs 5.57 ± 1.06). There was no effect of profession on ratings and no significant interaction between profession and gender of the team leader on ratings for any of the domains. CONCLUSIONS: These findings indicate bias among residents against females as team leaders. Mitigating such bias is essential to successfully establish shared leadership models in health care.

Exemplary Learning Environments for the Health Professions: A Vision.

In this article, the authors propose a vision for exemplary learning environments in which everyone involved in health professions education and health care collaborates toward optimal health for individuals, populations, and communities. Learning environments in the health professions can be conceptualized as complex adaptive systems, defined as a collection of individual agents whose actions are interconnected and follow a set of shared "simple rules." Using principles from complex adaptive systems as a guiding framework for the proposed vision, the authors postulate that exemplary learning environments will follow four such simple rules: Health care and health professions education share a goal of improving health for individuals, populations, and communities; in exemplary learning environments, learning is work and work is learning; exemplary learning environments recognize that collaboration with integration of diverse perspectives is essential for success; and the organizations and agents in the learning environments learn about themselves and the greater system they are part of in order to achieve continuous improvement and innovation. For each of the simple rules, the authors describe the details of the vision and how the current state diverges from this vision. They provide actionable ideas about how to reach the vision using specific examples from the literature. In addition, they identify potential targets for assessment to monitor the success of learning environments, including outcome measures at the individual, team, institutional, and societal levels. Such measurements can ensure optimal alignment between health professions education and health care and inform ongoing improvement of learning environments.

Useful but Different: Resident Physician Perceptions of Interprofessional Feedback.

UNLABELLED: Phenomenon: Based on recently formulated interprofessional core competencies, physicians are expected to incorporate feedback from other healthcare professionals. Based on social identity theory, physicians likely differentiate between feedback from members of their own profession and others. The current study examined residents' experiences with, and perceptions of, interprofessional feedback. APPROACH: In 2013, Anesthesia, Obstetrics-Gynecology, Pediatrics, and Psychiatry residents completed a survey including questions about frequency of feedback from different professionals and its perceived value (5-point scale). The authors performed an analysis of variance to examine interactions between residency program and profession of feedback provider. They conducted follow-up interviews with a subset of residents to explore reasons for residents' survey ratings. FINDINGS: Fifty-two percent (131/254) of residents completed the survey, and 15 participated in interviews. Eighty percent of residents reported receiving written feedback from physicians, 26% from nurses, and less than 10% from other professions. There was a significant interaction between residency program and feedback provider profession, F(21, 847) = 3.82, p < .001, and a significant main effect of feedback provider profession, F(7, 847) = 73.7, p < .001. On post hoc analyses, residents from all programs valued feedback from attending physicians higher than feedback from others, and anesthesia residents rated feedback from other professionals significantly lower than other residents. Ten major themes arose from qualitative data analysis, which revealed an overall positive attitude toward interprofessional feedback and clarified reasons behind residents' perceptions and identified barriers. Insights: Residents in our study reported limited exposure to interprofessional feedback and valued such feedback less than intraprofessional feedback. However, our data suggest opportunities exist for effective utilization of interprofessional feedback.

Does source matter? Nurses' and Physicians' perceptions of interprofessional feedback.

OBJECTIVE: Receptiveness to interprofessional feedback, which is important for optimal collaboration, may be influenced by 'in-group or out-group' categorisation, as suggested by social identity theory. We used an experimental design to explore how nurses and resident physicians perceive feedback from people within and outside their own professional group. METHODS: Paediatric residents and nurses participated in a simulation-based team exercise. Two nurses and two physicians wrote anonymous performance feedback for each participant. Participants each received a survey containing these feedback comments with prompts to rate (i) the usefulness (ii) the positivity and (iii) their agreement with each comment. Half of the participants received feedback labelled with the feedback provider's profession (two comments correctly labelled and two incorrectly labelled). Half received unlabelled feedback and were asked to guess the provider's profession. For each group, we performed separate three-way anovas on usefulness, positivity and agreement ratings to examine interactions between the recipient's profession, actual provider profession and perceived provider profession. RESULTS: Forty-five out of 50 participants completed the survey. There were no significant interactions between profession of the recipient and the actual profession of the feedback provider for any of the 3 variables. Among participants who guessed the source of the feedback, we found significant interactions between the profession of the feedback recipient and the guessed source of the feedback for both usefulness (F1,48 = 25.6; p < 0.001; η(2) = 0.35) and agreement ratings (F1,48 = 8.49; p < 0.01; η(2) = 0.15). Nurses' ratings of feedback they guessed to be from nurses were higher than ratings of feedback they guessed to be from physicians, and vice versa. Among participants who received labelled feedback, we noted a similar interaction between the profession of the feedback recipient and labelled source of feedback for usefulness ratings (F1,92 = 4.72; p < 0.05; η(2) = 0.05). CONCLUSION: Our data suggest that physicians and nurses are more likely to attribute favourably perceived feedback to the in-group than to the out-group. This finding has potential implications for interprofessional feedback practices.

Perceptions of Peer-to-Peer Interprofessional Feedback Among Students in the Health Professions.

PURPOSE: Interprofessional teamwork should include interprofessional feedback to optimize performance and collaboration. Social identity theory predicts that hierarchy and stereotypes may limit receptiveness to interprofessional feedback, but literature on this is sparse. This study explores perceptions among health professions students regarding interprofessional peer feedback received after a team exercise. METHOD: In 2012-2013, students from seven health professions schools (medicine, pharmacy, nursing, dentistry, physical therapy, dietetics, and social work) participated in a team-based interprofessional exercise early in clinical training. Afterward, they wrote anonymous feedback comments for each other. Each student subsequently completed an online survey to rate the usefulness and positivity (on five-point scales) of feedback received and guessed each comment's source. Data analysis included analysis of variance to examine interactions (on usefulness and positivity ratings) between profession of feedback recipients and providers. RESULTS: Of 353 study participants, 242 (68.6%) accessed the feedback and 221 (62.6%) completed the survey. Overall, students perceived the feedback as useful (means across professions = 3.84-4.27) and positive (means = 4.17-4.86). There was no main effect of profession of the feedback provider, and no interactions between profession of recipient and profession of provider regardless of whether the actual or guessed provider profession was entered into the analysis. CONCLUSIONS: These findings suggest that students have positive perceptions of interprofessional feedback without systematic bias against any specific group. Whether students actually use interprofessional feedback for performance improvement and remain receptive toward such feedback as they progress in their professional education deserves further study.

Perceptions of interprofessional teamwork in low-acuity settings: a qualitative analysis.

CONTEXT: Working effectively in interprofessional teams is a core competency for all health care professionals, yet there is a paucity of instruments with which to assess the associated skills. Published medical teamwork skills assessment tools focus primarily on high-acuity situations, such as cardiopulmonary arrests and crisis events in operating rooms, and may not generalise to non-high-acuity environments, such as in-patient wards and out-patient clinics. OBJECTIVE: We undertook the current study to explore the constructs underlying interprofessional teamwork in non-high-acuity settings and team members' perspectives of essential teamwork attributes. METHODS: We used an ethnographic approach to study four interprofessional teams in two different low-acuity settings: women's HIV (human immunodeficiency virus) clinics and in-patient paediatric wards. Over a period of 17 months, we collected qualitative data through direct observations, focus groups and individual interviews. We analysed the data using qualitative thematic analysis, following an iterative process: data from our observations (20 hours in total) informed the focus group guide and focus group data informed the interview guide. To enhance the integrity of our analysis, we triangulated data sources and verified themes through member checking. RESULTS: We conducted seven focus groups and 27 individual interviews with a total of 39 study participants representing eight professions. Participants emphasised shared leadership and collaborative decision making, mutual respect, recognition of one's own and others' limitations and strengths, and the need to nurture relationships. Team members also discussed tensions around hierarchy and questioned whether doctor leadership is appropriate for interprofessional teams. Our findings indicate that there are differences in teamwork between low-acuity and high-acuity settings, and also provide insights into potential barriers to effective interprofessional teamwork. CONCLUSIONS: Our study delineates essential elements of teamwork in low-acuity settings, including desirable attributes of team members, thus laying the foundation for the development of an individual teamwork skills assessment tool.

Career-long learning: relationship between cognitive and metacognitive skills.

OBJECTIVES: Physicians need metacognitive skills including reflection and goal generation for effective lifelong learning (LLL). These skills are not readily assessed and may not correlate with cognitive skills. We examined early-career physicians' metacognition and relationships between metacognitive skills, cognitive skills, and orientation toward LLL. METHODS: Pediatric fellows at UCSF document career progress in annual Individual Development Plans (IDPs). To assess metacognitive skills, we scored narratives in IDPs with a Reflective Ability Rubric (RAR) and goal setting with a SMART Goal Rubric (SMART-GR: consists of global IDP score and four IDP domain subscores). To assess cognitive skills, we collected American Board of Pediatrics scores (ABP), and to measure orientation toward LLL, fellows completed the Jefferson Scale (JeffSPLL). We used Spearman's correlation to examine relationships between scores. RESULTS: About 57/66 (86%) fellows participated. Mean scores were: RAR 2.4 ± 1.3 (scale 0-6); SMART-GR global IDP 2.8 ± 1.0, (1-5); JeffSPLL 46.3 ± 3.9 (14-56); and ABP 559.4 ± 75.7. RAR scores correlated significantly with SMART-GR scores but metacognitive measures did not correlate with ABP scores. CONCLUSIONS: Our study suggests early-career physicians may have limited metacognitive skills; cognitive and metacognitive skills do not correlate; and orientation toward LLL does not predict metacognitive skills. Thus, we need improved methods to teach and assess metacognition.