Sawatsky, Adam P.

Abstract Qualitative research was originally developed within the social sciences. Medical education is a field that comprises multiple disciplines, including the social sciences, and utilizes qualitative research to gain a broader understanding of key phenomena within the field. Many clinician educators are unfamiliar with qualitative research. This article provides a primer for clinician educators who want to appraise or conduct qualitative research in medical education. This article discusses a definition and the philosophical underpinnings for qualitative research. Using the Standards for Reporting Qualitative Research as a guide, this article provides a step-wise approach for conducting and evaluating qualitative research in medical education. This review will enable the reader to understand when to utilize qualitative research in medical education and how to interpret reports using qualitative approaches.

Abstract There has been a dramatic growth of scholarly articles in medical education in recent years. Evaluating medical education research requires specific orientation to issues related to format and content. Our goal is to review the quantitative aspects of research in medical education so that clinicians may understand these articles with respect to framing the study, recognizing methodologic issues, and utilizing instruments for evaluating the quality of medical education research. This review can be used both as a tool when appraising medical education research articles and as a primer for clinicians interested in pursuing scholarship in medical education.

Purpose International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents’ and fellows’ IHE experiences with patient death. Method The authors used applied thematic analysis to explore residents’ and fellows’ IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001–2017 and identified themes relating to experiences with patient death. Second, in 2016–2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis. Results Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions. Conclusions Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.

Background Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes. Methods Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains. Results Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a ‘bundle’. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen’s d=0.09, 95% CI 0.04 to 0.14, p<0.001, I2=56%), but no significant association between BR and patient knowledge (Cohen’s d=0.21, 95% CI −0.004 to –0.43, p=0.054, I2=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data. Conclusions BR have been implemented in a variety of hospital settings, often ‘bundled’ with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.

Purpose International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents’ experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation. Method The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents’ IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity. Results Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor–patient relationship; and medicine in its “purest form.” Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development. Conclusions IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.

Purpose Self-directed learning (SDL) is part of residency training, which residents desire guidance in implementing. To characterize SDL within the clinical context, this study explored residents’ perceptions of faculty members’ role in promoting and supporting resident SDL. Method Using a constructivist grounded theory approach, the authors conducted seven focus groups with 46 internal medicine residents at the Mayo Clinic Internal Medicine Residency Program from October 2014 to January 2015. Focus group transcripts were deidentified and processed through open coding and analytic memo writing. Guided by a previously developed SDL model, data were analyzed regarding faculty member involvement in resident SDL. Themes were organized and patterns were discussed at team meetings, with constant comparison with new data. Trustworthiness was established using two member-check sessions. Results The authors identified themes within the categories of faculty guidance for SDL, SDL versus other-directed learning (ODL), and faculty archetypes for supporting SDL. Clinical teachers play a key role in facilitating resident SDL and can provide guidance at each step in the SDL process. Residents discussed the distinction between SDL and ODL, highlighting the integrated nature of learning and interplay between the two approaches to learning. Residents identified themes relating to three archetypal approaches faculty implement to support resident SDL in the clinical environment (directed, collaborative, and role model SDL), with benefits and challenges of each approach. Conclusions This study underscores the importance of external guidance for resident SDL and expands on approaches faculty members can use to support SDL in the clinical context.

Purpose In-training evaluation reports (ITERs) constitute an integral component of medical student and postgraduate physician trainee (resident) assessment. ITER narrative comments have received less attention than the numeric scores. The authors sought both to determine what validity evidence informs the use of narrative comments from ITERs for assessing medical students and residents and to identify evidence gaps. Method Reviewers searched for relevant English-language studies in MEDLINE, EMBASE, Scopus, and ERIC (last search June 5, 2015), and in reference lists and author files. They included all original studies that evaluated ITERs for qualitative assessment of medical students and residents. Working in duplicate, they selected articles for inclusion, evaluated quality, and abstracted information on validity evidence using Kane’s framework (inferences of scoring, generalization, extrapolation, and implications). Results Of 777 potential articles, 22 met inclusion criteria. The scoring inference is supported by studies showing that rich narratives are possible, that changing the prompt can stimulate more robust narratives, and that comments vary by context. Generalization is supported by studies showing that narratives reach thematic saturation and that analysts make consistent judgments. Extrapolation is supported by favorable relationships between ITER narratives and numeric scores from ITERs and non-ITER performance measures, and by studies confirming that narratives reflect constructs deemed important in clinical work. Evidence supporting implications is scant. Conclusions The use of ITER narratives for trainee assessment is generally supported, except that evidence is lacking for implications and decisions. Future research should seek to confirm implicit assumptions and evaluate the impact of decisions.

Context Although many studies have demonstrated the benefits of mentoring in academic medicine, conceptual understanding has been limited to studies performed in North America and Europe. An ecological model of mentoring in academic medicine can provide structure for a broader understanding of the role of culture in mentoring. Objective The goal of this study was to explore the role of culture in the development and maintenance of mentoring relationships within the context of the University of Malawi College of Medicine. Methods A qualitative study using in‐depth, semi‐structured interviews and thematic analysis was conducted to explore the meaning of mentorship at the study institution. Criterion sampling was used to identify and recruit medical students, interns, registrars and faculty members. Study team members developed a codebook through open coding and applied it to all interview transcripts. Thematic analysis was used to identify and categorise themes according to an ecological model. Results A total of 46 participants from two major centres in Malawi were interviewed. Themes were identified within three domains: the intrapersonal; the interpersonal, and the institutional. Intrapersonal themes included Malawian politeness, mentoring needs, and friendliness and willingness to help. Interpersonal themes included understanding the role of the mentor, respect for elders, personal and professional boundaries, and perceptions of others. Institutional themes included the supervisor versus mentor, time pressures, tension about the scope of training, and the mentoring cycle. Conclusions This study highlights the strengths of and challenges imposed by culture to the provision of mentoring relationships at the study institution. It also highlights the central role of culture in mentoring and proposes an updated model for mentoring in academic medicine. This model can inform future research on mentoring and may serve as a model in the larger effort to provide faculty development in mentoring across sub‐Saharan Africa.