Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review.

OBJECTIVE: We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented. DESIGN: We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance. DATA SOURCES: We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022. ELIGIBILITY CRITERIA: We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described. DATA EXTRACTION AND SYNTHESIS: The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency. RESULTS: Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes. CONCLUSION: This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations. PROSPERO REGISTRATION NUMBER: CRD42022369208.

Numeracy Education for Health Care Providers: A Scoping Review.

INTRODUCTION: Health numeracy (numerical literacy) refers to an individual's ability to use numerical information to make effective health decisions. Numeracy is fundamental in the role of a health care provider, forming the basis of evidence-based medicine and effective patient-provider communication. Despite a high level of education, many health care providers struggle with numeracy. Numeracy is often integrated into training curricula; however, teaching modality, competencies covered, learner satisfaction, and effectiveness of these educational interventions varies. METHOD: A scoping review was conducted to explore and summarize what is known about numeracy skills education programs for health care providers. A comprehensive literature search was conducted from January 2010 to April 2021 in 10 databases. Controlled vocabulary terms and text words were used. The search was restricted to human studies, adults, and the English language. Articles were included if they were related to numeracy education for health care providers or trainees and provided details regarding methods, evaluation, and results. RESULTS: The literature search retrieved 31,611 results and 71 met the inclusion criteria. Most interventions were conducted in a university setting, and targeted nursing students, medical students, resident physicians, and pharmacy students. Common numeracy concepts included statistics/biostatistics, medication calculations, evidence-based medicine, research methodology, and epidemiology. A variety of teaching modalities were used, which most often combined active approaches (eg, workshops, laboratories, small-group exercises, and discussion boards) with passive approaches (eg, traditional lectures and didactic teaching). Measured outcomes included knowledge and skills, self-efficacy, attitudes, and engagement. DISCUSSION: Although efforts have been made to incorporate numeracy into training curricula, greater emphasis should be placed on developing strong numeracy skills in health care providers, particularly given the role numerical information plays in clinical decision making, evidence-based practices, and patient-provider communication.

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol.

INTRODUCTION: Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work. METHODS AND ANALYSIS: This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes. PROSPERO REGISTRATION NUMBER: CRD42022369208.

'It's like Taking a Sleeping Pill': Student Experience of Autonomous Sensory Meridian Response (ASMR) to Promote Health and Mental Wellbeing.

Autonomous Sensory Meridian Response (ASMR) is purposely elicited by some individuals to promote health and mental wellbeing. The aim of the current study was to explore how ASMR is used and its perceived benefits in a student population. We employed semi-structured qualitative interviews, with eight female students who self-reported as ASMR-sensitive users. Inductive thematic analysis, underpinned by a phenomenological framework, was applied to the data. Two themes, each with three subthemes, were identified; these highlighted the journey from first discovering ASMR to present experience and the use of ASMR to promote health and mental wellbeing both directly and indirectly. For some, ASMR was used daily, whilst for others it was used in a relapsing-remitting fashion: usage increased when struggling with mental wellbeing and was most often used as a tool to induce sleep or distraction when feeling anxious. Participants also reported ASMR-eliciting content as intriguing, and that the phenomenon was regarded as taboo. ASMR appears to play an important role in promoting health and mental wellbeing; frequency of use, preferred triggers, and purpose of use varied, highlighting its flexible and subjective nature. It provides a potential cost-effective tool in populations such as students where mental health needs are burgeoning.

The imperative for (and opportunities of) research on adaptive expertise in health professions education.

In this editorial, three Advances in Health Sciences Education editors argue for the importance and impact of adaptive expertise on the future of health professions education and work. They present a sample of the broad range of theory-informed research currently contributing to understanding and applying adaptive expertise in health professions education. They reflect on the unique opportunities that interdisciplinarity offers this endeavour. Finally they offer potential ways forward for continued efforts to advance collective understanding of education, expert development and health professions practice.

A randomized controlled trial of customized adherence enhancement (CAE-E): study protocol for a hybrid effectiveness-implementation project.

BACKGROUND: Mood-stabilizing medications are a cornerstone of treatment for people with bipolar disorder, though approximately half of these individuals are poorly adherent with their medication, leading to negative and even severe health consequences. While a variety of approaches can lead to some improvement in medication adherence, there is no single approach that has superior adherence enhancement and limited data on how these approaches can be implemented in clinical settings. Existing data have shown an increasing need for virtual delivery of care and interactive telemedicine interventions may be effective in improving adherence to long-term medication. METHODS: Customized adherence enhancement (CAE) is a brief, practical bipolar-specific approach that identifies and targets individual patient adherence barriers for intervention using a flexibly administered modular format that can be delivered via telehealth communications. CAE is comprised of up to four standard treatment modules including Psychoeducation, Communication with Providers, Medication Routines, and Modified Motivational Interviewing. Participants will attend assigned module sessions with an interventionist based on their reasons for non-adherence and will be assessed for adherence, functioning, bipolar symptoms, and health resource use across a 12-month period. Qualitative and quantitative data will also be collected to assess barriers and facilitators to CAE implementation and reach and adoption of CAE among clinicians in the community. DISCUSSION: The proposed study addresses the need for practical adherence interventions that are effective, flexible, and designed to adapt to different settings and patients. By focusing on a high-risk, vulnerable group of people with bipolar disorder, and refining an evidence-based approach that will integrate into workflow of public-sector care and community mental health clinics, there is substantial potential for improving bipolar medication adherence and overall health outcomes on a broad level. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov NCT04622150 on November 9, 2020.

Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review.

Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy.

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Rapid Knowledge Mobilization and Continuing Professional Development: Educational Responses to COVID-19.

INTRODUCTION: The field of Continuing Professional Development (CPD) has a role to play in supporting health care professionals as they respond to the COVID-19 pandemic. However, the evolving science of COVID-19, the need for quick action, and the disruption of conventional knowledge networks pose challenges to existing CPD practices. To meet these emergent and rapidly evolving needs, what is required is an approach to CPD that draws insights from the domain of knowledge mobilization (KMb). METHODS: This short report describes a research protocol for exploring rapid KMb responses to COVID-19 at one Canadian academic teaching hospital. The proposed research will proceed as a case study using a mixed methods design collecting quantitative (surveys and Web site use metrics) and qualitative data (interviews) from individuals involved in developing, using, and supporting the KMb resources. Analysis will proceed in two phases: descriptive analysis of data to share insights and integrative analysis of data to build theory. RESULTS: Results from this study will inform the immediate KMb and CPD contribution to the COVID-19 response. DISCUSSION: Findings from this study will also make a broader contribution to the field of CPD, theoretically informing intersections between KMb and CPD and therefore contributing to an integrated science of CPD.

Making Concepts Material: A Randomized Trial Exploring Simulation as a Medium to Enhance Cognitive Integration and Transfer of Learning.

BACKGROUND: Simulation affords opportunities to represent functional relationships between conceptual (eg, anatomy) and procedural knowledge (eg, needle insertion technique) in ways that make them accessible to our many senses. Despite deprioritizing realism, such simulations may encourage trainees to create cognitive connections between these knowledge (ie, cognitive integration), which may improve transfer of learning. However, the impact of such "integrated instruction" has not been examined in simulation-based training. We developed integrated video- and simulator-based instructional modules for lumbar puncture training and compared their impacts on participants' retention, transfer, and conceptual knowledge. METHODS: During 1 hour of simulation-based training, we randomized 66 medical students to receive either (a) video-based procedural-only instruction, (b) integrated video-based instruction, or (c) integrated simulator-based instruction. One week later, we tested participants' retention and transfer performances and their conceptual knowledge on a written test. RESULTS: Simple mediation analyses revealed that compared with participants receiving procedural-only instruction, participants receiving integrated instruction had superior retention and transfer outcomes, mediated by gains in conceptual knowledge (all P < 0.01). We found no significant differences between the integrated groups for retention, transfer, or conceptual knowledge (all P > 0.01). CONCLUSIONS: We extended previous findings, showing integrated instruction (video- or simulator-based) improved trainees' conceptual knowledge, which mediated their improved retention and transfer. As an innovation, we demonstrated how simulators can facilitate cognitive integration by making abstract conceptual-procedural relationships material. In suggesting how researchers might capitalize further on simulator-based integration, we offer an alternative framework for designing simulations that emphasizes cognitive processes rather than simulator fidelity.

The Basic Science of Patient-Physician Communication: A Critical Scoping Review.

PURPOSE: Strong verbal communication skills are essential for physicians. Despite a wealth of medical education research exploring communication skills training, learners struggle to become strong communicators. Integrating basic science into the curriculum provides students with conceptual knowledge that improves learning outcomes and facilitates the development of adaptive expertise, but the conceptual knowledge, or "basic science," of patient-provider communication is currently unknown. This review sought to address that gap and identify conceptual knowledge that would support improved communication skills training for medical trainees. METHOD: Combining the search methodology of Arksey and O'Malley with a critical analytical lens, the authors conducted a critical scoping review of literature in linguistics, cognitive psychology, and communications to determine: what is known about verbal communication at the level of word choice in physician-patient interactions? Studies were independently screened by 3 researchers during 2 rounds of review. Data extraction focused on theoretical contributions associated with language use and variation. Analysis linked patterns of language use to broader theoretical constructs across disciplines. RESULTS: The initial search returned 15,851 unique studies, and 271 studies were included in the review. The dominant conceptual groupings reflected in the results were: (1) clear and explicit language, (2) patient participation and activation, (3) negotiating epistemic knowledge, (4) affiliative language and emotional bonds, (5) role and identity, and (6) managing transactional and relational goals. CONCLUSIONS: This in-depth exploration supports and contextualizes theory-driven research of physician-patient communication. The findings may be used to support future communications research in this field and educational innovations based on a solid theoretical foundation.

Case Report: Defining Applicant Attributes to Be Prioritized in the Selection of Child and Adolescent Psychiatry Subspecialty Residents at the University of Toronto.

Background/Objectives: The child and adolescent psychiatry (CAP) subspecialty training program at the University of Toronto was among the first fully accredited CAP programs in Canada. As one of Canada's largest CAP subspecialty programs, we attract many excellent applicants annually. While objectivity and transparency in the selection of candidates have been valued, it was unclear which applicant attributes should be prioritized. This quality improvement project was undertaken to identify the key applicant attributes that should be prioritized for admission to the program. Materials/Methods: An initial list of attributes was compiled by project team members and feedback solicited. Through iterative design, this list was categorized into "end products," "branding attributes" and "generic attributes." The "end products" were removed as these represented outputs of training rather than attributes on which applicant selection should be based. Subsequent steps involved only the "branding" and "generic" attributes. A consensus-building exercise led to the creation of two short-lists of five attributes within each category. Finally, a paired-comparison forced choice methodology was used to determine the ranking of these attributes in order of importance when assessing applicants. Results: The final lists of "generic" and "branding" attributes developed through a consensus-building exercise are presented in rank order based on the paired-comparison methodology. The overall response rate for the forced choice electronic survey was 49% of faculty and learners. Conclusions/Discussion: This project used an iterative process of consensus building & pairwise comparison to prioritize key attributes for assessing trainee selection to the program. Going forward, these attributes will be incorporated into the file review and interview portions of our admissions process. In addition to emphasizing these priority attributes in admissions, there are implications for other aspects of the program including curriculum and faculty development, as well as guiding the overall mission and vision for the Division. A similar process could be undertaken by other training programs seeking to identify priority attributes for admission to their programs.

Assessing undergraduate medical education through a generalist lens.

PROBLEM BEING ADDRESSED: Medical schools aim to integrate the values of generalism into their undergraduate programs. However, currently no program has been described to measure the degree to which formal curricular materials represent generalist principles. OBJECTIVE OF PROGRAM: To quantify the generalism principles present in undergraduate medical education learning materials and to provide recommendations to enhance generalism content. PROGRAM DESCRIPTION: A review of the literature and accreditation documents was conducted to identify key elements of medical generalism. An evidence-informed tool, the Toronto Generalism Assessment Tool, was developed and applied to the new preclerkship undergraduate cases at the University of Toronto in Ontario. The findings regarding the presence of generalism principles and recommendations to enhance generalism content were provided to case developers. The recommendations were valued and were incorporated into subsequent iterations of the cases. CONCLUSION: This is the first report of a successful evidence-informed program to assess the degree of generalism reflected in undergraduate medical education curricular documents. This program can be used by other institutions wishing to review their curricula through a generalist lens.

Re-envisioning paradigms of education: towards awareness, alignment, and pluralism.

In this article we introduce a synthesis of education "paradigms," adapted from a multi-disciplinary body of literature and tailored to health professions education (HPE). Each paradigm involves a particular perspective on the purpose of education, the nature of knowledge, what knowledge is valued and included in the curriculum, what it means to learn and how learning is assessed, and the roles of teachers and learners in the learning process. We aim to foster awareness of how these different paradigms look in practice and to illustrate the importance of alignment between teaching, learning and assessment practices with paradigmatic values and assumptions. Finally, we advocate for a pluralistic approach that purposefully and meaningfully integrates paradigms of education, enhancing our ability to drive quality in HPE.

The myth of ivory tower versus practice-oriented research: A systematic review of randomised studies in medical education.

CONTEXT: A long-standing myth in medical education research is a divide between two different poles: research aiming to advance theory with little focus on practical applications ('ivory tower' research) and practically oriented research aiming to serve educators and decision-makers with little focus on advancing theory ('in-the-trenches' practice). We explored this myth in a sample of randomised medical education studies using Stokes' four-quadrant framework for the classification of research perspective. METHODS: We searched MEDLINE, Embase, CINAHL, PsychINFO, ERIC, Web of Science and Scopus for studies in medical education using a randomised design that were published between 1 January 2018 and 31 December 2018. We used Stokes' four-quadrant framework to categorise the studies according to their use of theory, concepts and their justification for practical use. We compared medical education research published in medical education journals and clinical journals. RESULTS: A total of 150 randomised studies were included in the analysis. The largest segment of studies (46.7%) was categorised as use-inspired basic research (Pasteur's Quadrant), closely followed by pure applied research (40.7%, Edison's Quadrant). Only a few studies were categorised as aiming to advance knowledge with no thought for practical educational application (2.0%, Bohr's Quadrant). The proportion of studies that included educational concepts and theory differed according to publication in clinical journals or medical education journals: 40.5% vs 71.8%, respectively, P < .001. There were no differences between journals with regard to the proportion of studies that included a practical educational or clinical rationale (P = .99). CONCLUSION: In a large sample of studies using randomised designs, we found no evidence to support the myth that medical education research divides between two singular poles represented by 'ivory tower research' and 'in-the-trenches practice'. We did confirm prevailing assumptions regarding an emphasis on non-theoretical medical education research in clinical journals.

Analysis of medical tourism at the Andrade port of entry.

BACKGROUND: Medical tourism, a term used to describe the practice of traveling to obtain medical services or products, is known to occur along the U.S.-Mexico border and has for some time. Despite the ever-increasing number of local border crossings, there is little research or monitoring done on the prevalence of medical tourism or to show the products and services sought. OBJECTIVES: To identify which medications and services are most frequently obtained, the reasons for these instances of medical tourism, perceived efficacy or satisfaction of the medications and services, and the likelihood of continuing to receive health care in Mexico. METHODS: Using a cross-sectional survey design, participants were recruited to participate in an anonymous electronic 12-question survey at or near the U.S.-Mexico border at the Andrade port of entry. All participants were waiting to cross or had just crossed the border through this port. Data were analyzed using descriptive statistics. RESULTS: A total of 427 surveys were collected for analysis. The respondents reported traveling from 29 states within the United States, as well as from 3 other countries. The average age of the participants was 64.5 years, with a range of 19-93 years. Cost was reported by 92% (n = 394) as the major factor to participate in medical tourism, and the most common income bracket reported was between $25,001 and $50,000 annually (n = 103). Dental (n = 124) was the most common medical service, and antibiotics (n = 225) were the most common class of medications sought. Most of the participants expressed the intent to continue to participate in medical tourism (n = 404). CONCLUSION: Most survey respondents felt that Mexican health care services are of the same or better quality compared with those in the United States, for a lower cost, and plan to participate in medical tourism moving forward. Many opportunities for future research exist on this topic, including follow-up surveys and laboratory analyses to compare medication samples.

Exploring why we learn from productive failure: insights from the cognitive and learning sciences.

Advances in Health Sciences Education (AHSE) has been at the forefront of the cognitive wave in health professions education for the past 25 years. One example is research on productive failure, a teaching strategy that asks learners to attempt to generate solutions to difficult problems before receiving instruction. This study compared the effectiveness of productive failure with indirect failure to further characterize the underpinning cognitive mechanisms of productive failure. Year one pharmacy students (N = 42) were randomly assigned to a productive failure or an indirect failure learning condition. The problem of estimating renal function based on serum creatinine was described to participants in the productive failure learning condition, who were then asked to generate a solution. Participants in the indirect failure condition learned about the same problem and were given incorrect solutions that other students had created, as well as the Cockcroft-Gault formula, and asked to compare and contrast the equations. Immediately thereafter all participants completed a series of tests designed to assess acquisition, application, and preparation for future learning (PFL). The tests were repeated after a 1-week delay. Participants in the productive failure condition outperformed those in the indirect failure condition, both on the immediate PFL assessment, and after a 1-week delay. These results emphasize the crucial role of generation in learning. When preparing novice students to learn new knowledge in the future, generating solutions to problems prior to instruction may be more effective than simply learning about someone else's mistakes. Struggle and failure are most productive when experienced personally by a learner because it requires the learner to engage in generation, which deepens conceptual understanding.