A qualitative study of medical educators’ perspectives on remediation: Adopting a holistic approach to struggling residents

Introduction: During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation.

Methods: We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis.

Results: Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation.

Conclusions: The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.     

Biomedicine and ‘Risky’ Retirement Destinations: Older Western Residents in Ubud,Bali

International retirement migration is often conflated with the generic emergence of a new stage in the life course, the third age. I describe how well-travelled, globally orientated retirees are drawn to and experience biomedical provision in ‘risky’ retirement destinations. Drawing on ethnographic research in Ubud, Bali, Indonesia, I consider how older Western residents shape, share, and manage their health concerns in light of an Indonesian biomedical system that is transforming in the context of modern medical provision and an emerging retirement industry. Building on Rose and Novas’s notion of biological citizenship, I illustrate the ways in which Western retirees engage with multiple biomedical realities built around localized, symbolic distinctions between ‘hospital’ and ‘doctor,’ immigration frameworks, the transregional context of medical tourism, and broader concerns relating to change and overdevelopment in Ubud and Bali.     

‘Like a Virgin’: Hymenoplasty and Secret Marriage in Egypt

In Egypt, women seek hymenoplasty to disguise evidence of premarital sexual intercourse. Physicians hide the fact that they perform the procedure, and laypeople condemn it as against religion and morality, a way of cheating men of knowledge of their wives’ sexual history. Yet high-ranking religious leaders have condoned hymenoplasty. Based on ethnographic fieldwork, archival research, and formal interviews with laypeople and physicians, in this article, I investigate this discrepancy between religious and lay opinions. Many Egyptians believe women resort to hymenoplasty after contracting secret `urfi (customary) marriages, and I examine the relationship between hymenoplasty and extramarital and paramarital sexuality. Egyptian debates around hymenoplasty and marriage are concerned with the notion that women’s sexual status must be socially visible, believing that doctors and kin have the ability and obligation to read women’s sexual history through physiological markers and social rituals. Hymenoplasty and secret marriage render women’s sexual histories illegible to observers.     

Moral Fiber: Breakfast as a Symbol of ‘a Good Start’ in an Australian Obesity Intervention

What are the symbolic meanings of breakfast in the context of one of Australia’s largest childhood obesity intervention programs? Utilizing a range of theoretical insights into the morality of food and eating and the anthropology of food, we trace how breakfast is packaged and promoted to families in an Australian community as a ‘healthy start’ to the day. Through ethnographic and historic investigation, we argue that eating breakfast and certain types of breakfast foods are symbolic of a classed, healthy lifestyle pattern, embodying parental knowledge and bodily regulation to routinely structure daily life. In communities where poverty and unemployment are harsh realities, well-intentioned programs that encourage people to eat a healthy breakfast are encoded with an assemblage of moral values—of knowledge, foods, families, and times and spaces—that are often difficult to reconcile with the wider sociocultural context in which many people live.     

“Conceiving God’s Children”: Toward a Flexible Model of Reproductive Decision-Making

Drawing on an ethnographic study of reproduction in Israel, in this article I demonstrate how Orthodox Jews delineate borders between the godly and the human in their daily reproductive practices. Exploring the multiple ways access to technology affects religious belief and observance, I describe three approaches to marital birth control, two of which are antithetical: steadfast resistance to and general acceptance of “calculated family planning.” Seeking a middle road, the third model, “flexible decision-making,” reveals how couples push off and welcome pregnancies simultaneously. Unravelling the illusion of a binary model of planned/unplanned parenthood, I call for nuanced models of reproductive decision-making.     

Plus ça change,plus c’est pareil: Making a continued case for the use of MCQs in medical education

Despite the increased emphasis on the use of workplace-based assessment in competency-based education models, there is still an important role for the use of multiple choice questions (MCQs) in the assessment of health professionals. The challenge, however, is to ensure that MCQs are developed in a way to allow educators to derive meaningful information about examinees’ abilities. As educators’ needs for high-quality test items have evolved so has our approach to developing MCQs. This evolution has been reflected in a number of ways including: the use of different stimulus formats; the creation of novel response formats; the development of new approaches to problem conceptualization; and the incorporation of technology. The purpose of this narrative review is to provide the reader with an overview of how our understanding of the use of MCQs in the assessment of health professionals has evolved to better measure clinical reasoning and to improve both efficiency and item quality.     

Bioethics as a second-order discipline: who is not a bioethicist?

A dispute exists about whether bioethics should become a new discipline with its own methods, competency standards, duties, honored texts, and core curriculum. Unique expertise is a necessary condition for disciplines. Using the current literature, different views about the sort of expertise that might be unique to bioethicists are critically examined to determine if there is an expertise that might meet this requirement. Candidates include analyses of expertise based in "philosophical ethics," "casuistry," "atheoretical or situation ethics," "conventionalist relativism," "institutional guidance," "regulatory guidance and compliance," "political advocacy," "functionalism," and "principlism." None succeed in identifying a unique area of expertise for successful bioethicists that could serve as a basis for making it a new discipline. Rather expertise in bioethics is rooted in many professions, disciplines and fields and best understood as a second-order discipline.     

Grappling with complexity: Medical students’ reflective writings about challenging patient encounters as a window into professional identity formation

Aim: Clerkship-specific interactive reflective writing (IRW)-enhanced reflection may enhance professional identity formation (PIF), a fundamental goal of medical education. PIF process as revealed in students? reflective writing (RW) has been understudied.

Methods: The authors developed an IRW curriculum within a Family Medicine Clerkship (FMC) and analyzed students? reflections about challenging/difficult patient encounters using immersion-crystallization qualitative analysis.

Results: The qualitative analysis identified 26 unique emergent themes and five distinct thematic categories (1. Role of emotions, 2. Role of cognition, 3. Behaviorally responding to situational context, 4. Patient factors, and 5. External factors) as well as an emergent PIF model from a directed content analysis. The model describes students? backgrounds, emotions and previous experiences in medicine merging with external factors and processed during student?patient interactions. The RWs also revealed that processing often involves polarities (e.g. empathy/lack of empathy or encouragement/disillusionment) as well as dissonance between idealized visions and lived reality.

Conclusions: IRW facilitates and ideally supports grappling with the lived reality of medicine; uncovering a “positive hidden curriculum” within medical education. The authors propose engaging learners in guided critical reflection about complex experiences for meaning-making within a safe learning climate as a valuable way to cultivate reflective, resilient professionals with “prepared” minds and hearts for inevitable challenges of healthcare practice.     

Insulin: a model system for nanomedicine?

One of the predominant aims of insulin therapy for diabetes is to appropriately mimic physiological insulin secretion levels and their correlation with glucose concentration in healthy individuals. This report outlines current methods and their limitations in glycemic control and their possible relationship to insufficient knowledge about the structure and dynamics of the insulin hormone itself. Based on recent experimental and computational work, a possible approach to less-invasive insulin administration is sketched.     

Formative assessment: a key to deep learning?

A paradigm shift in assessment culture has emphasized the importance of formative assessment. The existing evidence supports the identification of feedback as the central component of formative assessment. Feedback provides information about the existing gap between the actual and desired levels of performance. The existing evidence suggests various characteristics of effective feedback, for example, ensuring that feedback is construct-referenced and student referenced. An exploration of the existing educational literature provides evidence for the emphasis on formative assessment. This paper evaluates the pedagogical implications of formative assessment to deep learning. A constructivist approach, emphasizing the principles of adult learning and placing emphasis on the student is advocated. However, in applying the wider educational literature to healthcare, it is questioned if the paradigm shift in assessment culture has occurred as the majority of the existing literature is centred on summative assessment.