Cynthia Whitehead

The doctor dilemma in interprofessional education and care: how and why will physicians collaborate?

Context  Interprofessional educational (IPE) initiatives are seen as a means to engage health care professionals in collaborative patient‐centred care. Given the hierarchical nature of many clinical settings, it is important to examine how the aims of formal IPE courses intersect with the socialisation of medical students into roles of responsibility and authority.

Cognition before curriculum: rethinking the integration of basic science and clinical learning.

Purpose Integrating basic science and clinical concepts in the undergraduate medical curriculum is an important challenge for medical education. The health professions education literature includes a variety of educational strategies for integrating basic science and clinical concepts at multiple levels of the curriculum. To date, assessment of this literature has been limited. Method In this critical narrative review, the authors analyzed literature published in the last 30 years (1982–2012) using a previously published integration framework. They included studies that documented approaches to integration at the level of programs, courses, or teaching sessions and that aimed to improve learning outcomes. The authors evaluated these studies for evidence of successful integration and to identify factors that contribute to integration. Results Several strategies at the program and course level are well described but poorly evaluated. Multiple factors contribute to successful learning, so identifying how interventions at these levels result in successful integration is difficult. Evidence from session-level interventions and experimental studies suggests that integration can be achieved if learning interventions attempt to link basic and clinical science in a causal relationship. These interventions attend to how learners connect different domains of knowledge and suggest that successful integration requires learners to build cognitive associations between basic and clinical science. Conclusions One way of understanding the integration of basic and clinical science is as a cognitive activity occurring within learners. This perspective suggests that learner-centered, content-focused, and session-level-oriented strategies can achieve cognitive integration.

The impact of space and time on interprofessional teamwork in Canadian primary health care settings: implications for health care reform

Aim This paper explores the impact of space and time on interprofessional teamwork in three primary health care centres and the implications for Canadian and other primary health care reform. Background Primary health care reform in Canada has emphasized the creation of interprofessional teams for the delivery of collaborative patient-centred care. This involves the expansion and transformation of existing primary health care centres into interprofessional family health teams (FHT) promising to provide patients better access, more comprehensive care, and improved utilization of individual health professionals. Benefits for providers include improved workplace satisfaction and organizational efficiencies. Currently, there is little evidence for how effective interprofessional teamwork happens and little is known about how to create high-functioning teams in the primary health care setting. Methods We used ethnographic observations and interviews to gain a deep understanding of the nature of interprofessional teamwork. Three academic family health centres participated in a total of 139 h of observation and 37 interviews. Team members in all three centres from the disciplines of medicine, nursing, physiotherapy, occupational therapy, social work, dietetics, pharmacy, and office administration participated in this study. Findings We found that both the quantity and quality of interprofessional communication and collaboration in primary health care is significantly impacted by space and time. Across our research sites, the physical layout of clinical space and the temporal organization of clinical practice led to different approaches to, and degrees of success with, interprofessional teamwork. Varied models of interprofessional collaboration resulted when these factors came together in different ways. These findings have important implications for the transition to interprofessional family health teams in Canada and beyond.

Flower Power: The Armoured Expert in the CanMEDS Competency Framework?.

Competency frameworks based on roles definitions are currently being used extensively in health professions education internationally. One of the most successful and widely used models is the CanMEDS Roles Framework. The medical literature has raised questions about both the theoretical underpinnings and the practical application of outcomes-based frameworks, however little empirical research has yet been done examining specific roles frameworks. This study examines the historical development of an important early roles framework, the Educating Future Physicians of Ontario (EFPO) roles, which were instrumental in the development of the CanMEDS roles. Prominent discourses related to roles development are examined using critical discourse analysis methodology. Exploration of discourses that emerged in the development of this particular set of roles definitions highlights the contextual and negotiated nature of roles construction. The discourses of threat and protection prevalent in the EFPO roles development offer insight into the visual construction of a centre of medical expertise surrounded by supporting roles (such as collaborator and manager). Non-medical expert roles may perhaps play the part of ‘armour’ for the authority of medical expertise under threat. This research suggests that it may not be accurate to consider roles as objective ideals. Effective training models may require explicit acknowledgement of the socially negotiated and contextual nature of roles definitions.

Conceptual and practical challenges in the assessment of physician competencies.

Abstract The shift to using outcomes-based competency frameworks in medical education in many countries around the world requires educators to find ways to assess multiple competencies. Contemporary medical educators recognize that a competent trainee not only needs sound biomedical knowledge and technical skills, they also need to be able to communicate, collaborate and behave in a professional manner. This paper discusses methodological challenges of assessment with a particular focus on the CanMEDS Roles. The paper argues that the psychometric measures that have been the mainstay of assessment practices for the past half-century, while still valuable and necessary, are not sufficient for a competency-oriented assessment environment. New assessment approaches, particularly ones from the social sciences, are required to be able to assess non-Medical Expert (Intrinsic) roles that are situated and context-bound. Realist and ethnographic methods in particular afford ways to address the challenges of this new assessment. The paper considers the theoretical and practical bases for tools that can more effectively assess non-Medical Expert (Intrinsic) roles.

Captive on a carousel: discourses of ‘new’ in medical education 1910–2010

Medical educators aim to train physicians with sound scientific knowledge, expert clinical skills and an ability to work effectively with patients, colleagues and health systems. Over the past century, educators have devoted considerable thought and effort to how medical education might be improved. Analysing the language used to describe these initiatives provides insight into assumptions and practices. The authors conducted a Foucauldian critical discourse analysis of prominent recurrent themes in the North American medical education literature. The assembled archive of texts included works of Abraham Flexner, articles from the journal Academic Medicine (including its predecessor journals) and major medical education reports. A series of recurring themes were identified, including the need to avoid over-specialization, the importance of generalism, and the need to broaden criteria for medical student selection. Analysis of these recurring themes allowed identification of a prominent and recurrent discourse of ‘new.’ This discourse places focus on the future, ignores the ongoing historical nature of issues, suggests a sense of urgency and enables the proposal of modest solutions. It emphasizes changes for individual future doctors, thereby limiting consideration of institutional and systemic factors. Using the image of a carousel, the regular return of themes can be seen as carousel ponies circling around repeatedly in medical education. Identification of this medical education carousel provides an opportunity for medical educators to understand the historical nature of calls for change, and to consider what kinds of reform might be required if they wish to avoid this repetition in the future.

New Delhi metallo- β-lactamase-1: local acquisition in Ontario, Canada, and challenges in detection

New Delhi metallo-β-lactamase-1 (NDM-1) is a recently identified metallo-β-lactamase that confers resistance to carbapenems and all other β-lactam antibiotics, with the exception of aztreonam. NDM-1 is also associated with resistance to many other classes of antibiotics. The enzyme was first identified in organisms isolated from a patient in Sweden who had previously received medical treatment in India, but it is now recognized as endemic throughout India and Pakistan and has spread worldwide. The gene encoding NDM-1 has been found predominantly in Escherichia coli and Klebsiella pneumoniae. We describe the isolation NDM-1–producing organisms from two patients in Toronto, Ontario. To the best of our knowledge, this is the first report of an organism producing NDM-1 that was locally acquired in Canada. We also discuss the evidence that NDM-1 can affect bacterial species other than E. coli and K. pneumoniae, the limited options for treatment and the difficulty laboratories face in detecting organisms that produce NDM-1.

Medical education… meet Michel Foucault

There have been repeated calls for the greater use of conceptual frameworks and of theory in medical education. Although it is familiar to few medical educators, Michel Foucaults work is a helpful theoretical and methodological source.

Louder than words: power and conflict in interprofessional education articles, 1954-2013

Interprofessional education (IPE) aspires to enable collaborative practice. Current IPE offerings, although rapidly proliferating, lack evidence of efficacy and theoretical grounding.

Looking back to move forward: Using history, discourse and text in medical education research: AMEE Guide No. 73

As medical education research continues to diversify methodologically and theoretically, medical education researchers have been increasingly willing to challenge taken-for-granted assumptions about the form, content and function of medical education. In this AMEE Guide we describe historical, discourse and text analysis approaches that can help researchers and educators question the inevitability of things that are currently seen as ‘natural’. Why is such questioning important? By articulating our assumptions and interrogating the ‘naturalness’ of the status quo, one can then begin to ask why things are the way they are. Researchers can, for example, ask whether the models of medical education organization and delivery that currently seem ‘natural’ to them have been developed in order to provide the most benefit to students or patients – or whether they have, rather, been developed in ways that provide power to faculty members, medical schools or the medical profession as a whole. An understanding of the interplay of practices and power is a valuable tool for opening up the field to new possibilities for better medical education. The recognition that our current models, rather than being ‘natural’, were created in particular historical contexts for any number of contingent reasons leads inexorably to the possibility of change. For if our current ways of doing things are not, in fact, inevitable, not only can they be questioned, they can be made better; they can changed in ways that are attentive to whom they benefit, are congruent with our current beliefs about best practice and may lead to the production of better doctors.