Brian Hodges

Cracks and crevices: Globalization discourse and medical education

Globalization discourse, and its promises of a ‘flat world’, ‘borderless economy’ and ‘mobility of ideas and people’, has become very widespread in all fields. In medical education this discourse is underpinned by assumptions that medical competence has universal elements and that medical education can therefore develop ‘global standards’ for accreditation, curricula and examinations. Yet writers in the field other than medicine have raised a number of concerns about an overemphasis on the economic aspects of globalization. This article explores the notion that it is time to study and embrace differences and discontinuities in goals, practices and values that underpin medical competence in different countries and to critically examine the promises–realized or broken–of globalization discourse in medical education.

The future of medical education: a Canadian environmental scan.

Medical Education 2011: 45: 95–106

A Comparison of Health Access Between Permanent Residents, Undocumented Immigrants and Refugee Claimants in Toronto, Canada

Understanding the immigrant experience accessing healthcare is essential to improving their health. This qualitative study reports on experiences seeking healthcare for three groups of immigrants in Toronto, Canada: permanent residents, refugee claimants and undocumented immigrants. Undocumented immigrants who are on the Canadian Border Services Agency deportation list are understudied in Canada due to their precarious status. This study will examine the vulnerabilities of this particular subcategory of immigrant and contrast their experiences seeking healthcare with refugee claimants and permanent residents. Twenty-one semi-structured, one-on-one qualitative interviews were conducted with immigrants to identify barriers and facilitators to accessing healthcare. The open structure of the interviews enabled the participants to share their experiences seeking healthcare and other factors that were an integral part of their health. This study utilized a community-based participatory research framework. The study identifies seven sections of results. Among them, immigration status was the single most important factor affecting both an individual’s ability to seek out healthcare and her experiences when trying to access healthcare. The healthcare seeking behaviour of undocumented immigrants was radically distinct from refugee claimants or immigrants with permanent resident status, with undocumented immigrants being at a greater disadvantage than permanent residents and refugee claimants. Language barriers are also noted as an impediment to healthcare access. An individual’s immigration status further complicates their ability to establish relationships with family doctors, access prescriptions and medications and seek out emergency room care. Fear of authorities and the complications caused by the above factors can lead to the most disadvantaged to seek out informal or black market sources of healthcare. This study reaffirmed previous findings that fear of deportation forestalls undocumented immigrants from seeking out healthcare through standard means. The findings bring to light issues not discussed in great depth in the current literature on immigrant health access, the foremost being the immigration status of an individual is a major factor affecting that person’s ability to seek, and experience of, healthcare services. Further, that undocumented immigrants have difficulty gaining access to pharmaceuticals and so may employ unregulated means to obtain medication, often with the assistance of a doctor. Also, there exists two streams of healthcare access for undocumented immigrants—from conventional healthcare facilities but also from informal systems delivered mainly through community-based organizations. Finally, within the umbrella term ‘immigrant’ there appears to be drastically different healthcare utilization patterns and attitudes toward seeking out healthcare between the three subgroups of immigrants addressed by this study.

Interprofessional education for delirium care: a systematic review

Abstract Recent delirium prevention and treatment guidelines recommend the use of an interprofessional team trained and competent in delirium care. We conducted a systematic review to identify the evidence for the value of interprofessional delirium education programs on learning outcomes. We searched several databases and the grey literature. Studies describing an education intervention, involving two or more healthcare professions and reporting on at least one learning outcome as classified by Kirkpatrick’s evaluation framework were included in this review. Ten out of 633 abstracts reviewed met the study inclusion criteria. Several studies reported on more than one learning outcome. Two studies focused on learner reactions to interprofessional delirium education; three studies focused on learning outcomes (e.g. delirium knowledge); six studies focused on learner behavior in practice; and six studies reported on learning results (e.g. patient outcomes), mainly changes in delirium rates post-intervention. Studies reporting changes in patient outcomes following the delirium education intervention used an interprofessional practice (IPP) intervention in combination with interprofessional education (IPE). Our review of the limited evidence suggests that IPE programs may influence team and patient outcomes in delirium care. More systematic studies of the effectiveness of interprofessional delirium education interventions are needed.

End-of-Life Care Education for Psychiatric Residents: Attitudes, Preparedness, and Conceptualizations of Dignity.

ObjectiveThe authors examined psychiatric residents’ attitudes, perceived preparedness, experiences, and needs in end-of-life care education. They also examined how residents conceptualized good end-of-life care and dignity.MethodsThe authors conducted an electronic survey of 116 psychiatric residents at the University of Toronto. The survey had a mix of qualitative and quantitative questions.ResultsEighty-two of116 invited psychiatric residents participated for a response rate of 71%. With favorable attitudes, residents felt least prepared in existential, spiritual, cultural, and some psychological aspects of caring for dying patients. Trainees conceptualized dignity at the end of life in a way very similar to that of patients, including concerns of the mind, body, soul, relationships, and autonomy. Residents desired more longitudinal, contextualized training, particularly in the psychosocial, existential, and spiritual aspects of care.ConclusionThis is the first study to examine the end-of-life educational experience of psychiatric residents. Despite conceptualizing quality care and the construct of dignity similarly to dying patients, psychiatric residents feel poorly prepared to deliver such care, particularly the nonphysical aspects of caring for the dying. These results will inform curriculum development in end-of-life care for psychiatric residents, a complex area now considered a core competency.

The more it changes; the more it remains the same: a foucauldian analysis of Canadian policy documents relevant to student selection for medical school

Calls to increase the demographic representativeness of medical classes to better reflect the diversity of society are part of a growing international trend. Despite this, entry into medical school remains highly competitive and exclusive of marginalized groups. To address these questions, we conducted a Foucauldian discourse analysis of 15 publically available policy documents from the websites of Canadian medical education regulatory bodies, using the concepts of “excellence” (institutional or in an applicant), “diversity,” and “equity” to frame the analysis. In most documents, there were appeals to broaden definitions of institutional excellence to include concerns for greater social accountability. Equity concerns tended to be represented as needing to be dealt with by people in positions of authority in order to counter a “hidden curriculum.” Diversity was represented as an object of value, situated within a discontinuous history. As a rhetorical strategy, documents invoked complex societal shifts to promote change toward a more humanistic medical education system and profession. “Social accountability” was reified as an all-encompassing solution to most issues of representation. Although the policy documents proclaimed rootedness in an ethos of improving the societal responsiveness of the medical profession, our analysis takes a more critical stance towards the discourses identified. On the basis of our research findings, we question whether these calls may contribute to the maintenance of the specific power relations they seek to address. These conclusions lead us to consider the possibility that the discourses represented in the documents might be reframed to take into account issues of power distribution and its productive and reproductive features. A reframing of discourses could potentially generate greater inclusiveness in policy development processes, and afford disadvantaged and marginalized groups more participatory roles in the discussion.

Toward a research agenda for competency-based medical education.

Abstract Competency-based medical education (CBME) is both an educational philosophy and an approach to educational design. CBME has already had a broad impact on medical schools, residency programs, and continuing professional development in health professions around the world. As the CBME movement evolves and CBME programs are implemented, a wide range of emerging research questions will warrant scholarly examination. In this paper, we describe a proposed CBME research agenda developed by the International CBME Collaborators. The resulting framework includes questions about the meaning of key concepts of CBME and their implications for learners, faculty members, and institutional structures. Other research questions relate to the learning process, the meaning of entrustment decisions, fundamental measurement issues, and the nature and definition of standards. The exploration of these questions will help to solidify the theoretical foundation of CBME, but many issues related to implementation also need to be addressed. These pertain to, among other things, nurturing independent learning, assembling and using assessment results to make decisions about competence, structuring feedback, supporting remediation, and how best to evaluate the longer-term outcomes of CBME. High-quality research on these questions will require rigorous outcome measures with strong validity evidence. The complexity of CBME necessitates theoretical and methodological diversity. It also requires multi-institutional studies that examine effects at multiple levels, from the learner to the team, the institution, and the health care system. Such a framework of research questions can guide and facilitate scholarly discourse on the theoretical and practical body of knowledge related to competency-based health professions education.

The Psychiatry OSCE: A 20-Year Retrospective

ObjectiveTwenty years ago researchers at the University of Toronto launched the Psychiatry Skills Assessment Project (PSAP), a research program exploring Objective Structured Clinical Examinations (OSCEs) in psychiatry. Between 1994 and 2005 PSAP produced publications on the feasibility, reliability, validity, ethics, and practical concerns of OSCEs in psychiatry. The current review has two parts: a review of the state of the art of OSCEs in psychiatry 20xa0years after they were introduced and documentation of the impact of the PSAP research program.MethodsA literature search identified all publications on OSCEs and psychiatry. Articles were coded thematically, and locations of agreement and controversies were identified. Bibliometric analysis identified citations of PSAP research papers, which were analyzed thematically.ResultsAs of May 2013, there were 250 publications related to OSCEs in psychiatry (not including 10 PSAP papers), published in 29 different countries and ten languages. Prominent topics were the validity and acceptability of OSCEs and SPs, systems issues in adopting OSCEs in psychiatry, and the effects on learning. Eighty-eight percent of all publications cited PSAP work (300 citations). Citations were employed for four purposes: as evidence/justification (54xa0%); to frame replication research (14xa0%); to support adaptation of OSCEs in other countries and professions (15xa0%); and for debate (18xa0%).ConclusionsOver the past 20xa0years, use of OSCEs has grown steadily in psychiatry, and several national certification organizations have adopted OSCEs. PSAP work, introduced two decades ago, continues to provide a scholarly foundation for psychometric, practical, and ethical issues of interest to this field.

Who Should Be an OSCE Examiner

In this issue, Whelan et al. (1) address the question of who (standardized patients or physicians) should grade the performance of students taking Objective Structured Clinical Examinations (OSCEs). This is an interesting issue that has educational as well as socioeconomic dimensions. The last three decades of the 20th century were characterized by a significant shift in the way physician competence in Anglo-Saxon countries has been defined and assessed. The adoption of performance-based frameworks, such as the influential “Millers Pyramid” (2), placed more emphasis on what physicians could do rather than what they know. During the same period, the influence of medical educators with training in psychometrics led to a much greater emphasis on standardization, reliability, and validity in assessment. Together, the adoption of performance and psychometric discourses created a fertile ground for new assessment technologies such as the OSCE. No longer a novelty at the end of the first decade of the 21st century, OSCEs have been widely implemented by health professions around the world, including psychiatry (3). Mental health professionals need no convincing that one of the core competencies tested in an OSCE, or in any performance-based examination for that matter, is communication skills. However, whether communication skills are a unified construct is less clear. Our group (4) has reported that the appropriateness of specific communication skills (e.g., open-ended versus directed questioning) varies greatly according to the clinical problem encountered. For example, the often-taught communication style that gives priority to open-ended questions and listening is appropriate to a passive and withdrawn patient but entirely inadequate for an agitated manic patient. And although the first item of most communication scales is “makes eye contact,” we know that in some cultures direct eye contact is considered intrusive and uncomfortable. Therefore, to some degree, what is “appropriate” competence in a performance-based examination is a matter of perspective. So who is best positioned to assess the adequacy of student competence in a performance-based examination? Whelan et al. (1) follow the tradition of addressing this question from a psychometric perspective of “accuracy” (5–7), that is, the rater who is best able to reliably and consistently (psychometrically) score performances is considered the most appropriate examiner. This raises the interesting issue of what it actually means to be an examiner. At one extreme, we have interviewed individuals who argued, “There are no evaluators in the room, there are merely observers” (8). The implication is that the markers are “merely identifying behaviors that individuals perform and [that] it is the responsibility of the test administrators to compile those records into evaluations and numbers.” This idea arises from the often-made, but seldom-explicated, distinction between “assessment” and “evaluation” (9). Assessment is a process by which information is obtained relative to some known objective or goal. Assessment of skill attainment is rather straightforward. Either the skill exists at some acceptable level or it does not. Skills are readily demonstrable. Inherent in the idea of evaluation is “value.” When we evaluate, what we are doing is engaging in some process that is designed to provide information that will help us make a judgment about a given situation. When we evaluate, we are saying that the process will yield information regarding the worthiness, appropriateness, goodness, validity, legality, etc., of something for which a reliable measurement or assessment has been made. From this perspective, the “veracity” of the recording of a dispassionate and neutral observer is all that matters for “reliable assessment.” This view is congruent with a positivist conception that there is a reality/truth that can be Received September 8, 2008; accepted September 18, 2008. The authors are affiliated with the Department of Psychiatry at the Wilson Centre for Research in Education, University of Toronto, in Toronto, Ontario. Address correspondence to Brian David Hodges, M.D., Ph.D., Wilson Centre for Research in Education, Department of Psychiatry/University of Toronto, University Health Network-Toronto General Hospital, 200 Elizabeth St., 8 Easton, Rm 212, Toronto, Ontario M5G-2C4, Canada; brian. hodges@utoronto.ca (e-mail). Copyright

Asking new questions with qualitative research: A reflection on AMEE 2009

As recently as five years ago, the medical education journals were rife with articles (Albert 2004; Bligh 2003; Norman 1998) arguing about the nature and contents of appropriate research in medical...