Ilgen, Jonathan S.

Abstract Background Hospitalists work in complex clinical environments with rising patient acuity and competing demands. Uncertainty is an inescapable part of this work, yet little is known about how hospitalists experience and manage clinical uncertainty. Objectives To explore how hospitalists experience and manage uncertainty in clinical practice. Methods We conducted a single‐center qualitative study using reflexive thematic analysis within a constructivist paradigm. We interviewed hospitalist attending physicians during and/or after their work week and analyzed data inductively, drawing on literature about uncertainty in other clinical contexts. To strengthen rigor and trustworthiness, we held return‐of‐findings feedback sessions with participants. Results We interviewed 12 hospitalists between April 2023 and September 2024. Across diverse clinical situations, participants framed uncertainty through the lens of hospital discharge, using it as an anchor for decision‐making. Managing uncertainty required cognitive and emotional resources and was influenced by participants’ “bandwidth,” or perceived capacity to manage competing professional and personal demands. Perceived bandwidth shaped participants’ responses to uncertainty. Adequate bandwidth encouraged uncertainty engagement, while limited bandwidth prompted deferral or offloading. Participants described how they attempted to ease the burden of uncertainty for their oncoming colleagues by adjusting their documentation and care plans during handoffs. Conclusions Hospitalists experience uncertainty as a routine part of clinical practice and manage it pragmatically to advance patients toward discharge. Their approaches are shaped by their perceived bandwidth. The influences of uncertainty should be considered when assessing workload, organizing clinical service, and planning handoffs.

Abstract Purpose Professional identities impact professional boundaries and hierarchies, influencing how physicians approach collaboration. Despite the growing emphasis on developing students to become effective collaborators, little is known about how other health professionals (OHPs) shape students' professional identity formation (PIF). This study explored how interacting with OHPs during clinical care contributed to medical students' construction of what it means to be a physician. Methods For this constructivist grounded theory study, researchers conducted 20 semi‐structured interviews with medical students during clinical clerkships. Students drew rich pictures representing their interactions with OHPs and described these pictures during their interviews. Interviews were iteratively conducted and analysed, enabling the research team to theorize how interacting with OHPs contributed to medical students' PIF. Results Participants expressed a strong desire to contribute to patient care and described how interprofessional interactions provided opportunities to do so in ways aligned with their current capabilities. These opportunities were often more accessible than the roles and responsibilities of physicians, and participating alongside OHPs fostered participants' sense of their own developing capabilities and belonging on healthcare teams. Interactions with OHPs helped participants to see the expertise of OHPs and the value of collaborating with them in ways that shifted their focus away from becoming independent. Conceptually, participants' interactions with OHPs became both a mirror reflecting their present readiness to meaningfully contribute and a prism through which they could envision their future identities as physicians in new ways. Conclusions Interprofessional interactions influenced medical students' current and future professional identities, enabling students to see themselves as contributors on health care teams and highlighting collaboration and interdependence as core attributes of the physician profession. These findings highlight opportunities to amplify the impact of interprofessional interactions on the PIF of medical students and the need for research into how OHPs view their roles in these processes.

Abstract Introduction To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. Methods We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5‐hour session involving a rich picture drawing and one‐on‐one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. Results We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre‐existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. Conclusion This study uncovers an ideology that shapes residents' developing professional identity—an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Context The relative advantages and disadvantages of checklists and global rating scales ( GRS s) have long been debated. To compare the merits of these scale types, we conducted a systematic review of the validity evidence for checklists and GRS s in the context of simulation‐based assessment of health professionals. Methods We conducted a systematic review of multiple databases including MEDLINE , EMBASE and S copus to F ebruary 2013. We selected studies that used both a GRS and checklist in the simulation‐based assessment of health professionals. Reviewers working in duplicate evaluated five domains of validity evidence, including correlation between scales and reliability. We collected information about raters, instrument characteristics, assessment context, and task. We pooled reliability and correlation coefficients using random‐effects meta‐analysis. Results We found 45 studies that used a checklist and GRS in simulation‐based assessment. All studies included physicians or physicians in training; one study also included nurse anaesthetists. Topics of assessment included open and laparoscopic surgery ( n = 22), endoscopy ( n = 8), resuscitation ( n = 7) and anaesthesiology ( n = 4). The pooled GRS –checklist correlation was 0.76 (95% confidence interval [ CI ] 0.69–0.81, n = 16 studies). Inter‐rater reliability was similar between scales ( GRS 0.78, 95% CI 0.71–0.83, n = 23; checklist 0.81, 95% CI 0.75–0.85, n = 21), whereas GRS inter‐item reliabilities (0.92, 95% CI 0.84–0.95, n = 6) and inter‐station reliabilities (0.80, 95% CI 0.73–0.85, n = 10) were higher than those for checklists (0.66, 95% CI 0–0.84, n = 4 and 0.69, 95% CI 0.56–0.77, n = 10, respectively). Content evidence for GRS s usually referenced previously reported instruments ( n = 33), whereas content evidence for checklists usually described expert consensus ( n = 26). Checklists and GRS s usually had similar evidence for relations to other variables. Conclusions Checklist inter‐rater reliability and trainee discrimination were more favourable than suggested in earlier work, but each task requires a separate checklist. Compared with the checklist, the GRS has higher average inter‐item and inter‐station reliability, can be used across multiple tasks, and may better capture nuanced elements of expertise.

Abstract Objectives Technology‐enhanced simulation is used frequently in emergency medicine ( EM ) training programs. Evidence for its effectiveness, however, remains unclear. The objective of this study was to evaluate the effectiveness of technology‐enhanced simulation for training in EM and identify instructional design features associated with improved outcomes by conducting a systematic review. Methods The authors systematically searched MEDLINE , EMBASE , CINAHL , ERIC , Psych INFO , Scopus, key journals, and previous review bibliographies through May 2011. Original research articles in any language were selected if they compared simulation to no intervention or another educational activity for the purposes of training EM health professionals (including student and practicing physicians, midlevel providers, nurses, and prehospital providers). Reviewers evaluated study quality and abstracted information on learners, instructional design (curricular integration, feedback, repetitive practice, mastery learning), and outcomes. Results From a collection of 10,903 articles, 85 eligible studies enrolling 6,099 EM learners were identified. Of these, 56 studies compared simulation to no intervention, 12 compared simulation with another form of instruction, and 19 compared two forms of simulation. Effect sizes were pooled using a random‐effects model. Heterogeneity among these studies was large (I 2 ≥ 50%). Among studies comparing simulation to no intervention, pooled effect sizes were large (range = 1.13 to 1.48) for knowledge, time, and skills and small to moderate for behaviors with patients (0.62) and patient effects (0.43; all p < 0.02 except patient effects p = 0.12). Among comparisons between simulation and other forms of instruction, the pooled effect sizes were small (≤0.33) for knowledge, time, and process skills (all p > 0.1). Qualitative comparisons of different simulation curricula are limited, although feedback, mastery learning, and higher fidelity were associated with improved learning outcomes. Conclusions Technology‐enhanced simulation for EM learners is associated with moderate or large favorable effects in comparison with no intervention and generally small and nonsignificant benefits in comparison with other instruction. Future research should investigate the features that lead to effective simulation‐based instructional design.