Under the leadership of the late Professor Sam Fehrsen, the Medunsa MPraxMed, which commenced in 1979, was an innovative programme offering doctors in South Africa the unique opportunity to be trained in family medicine within the context of their workplaces. This article describes its pedagogical approach that profoundly influenced a generation of family physicians. Eight shifts in learning arose out of the programme’s development and iterative renewal. These included a focus on context and real-world application, greater autonomy for students with learning being focused on their needs, modelling the doctor–patient relationship in the educator-student relationship, facilitation of learning more than teaching, offering resources rather than courses, lecturers and students being co-learners and supporting reflective action. Most of the shifts in the Medunsa MPraxMed are now recognised as good educational practice underpinned by evidence, and are still necessary today. Contribution: Current postgraduate family medicine training programmes in South Africa and beyond are offered the opportunity to reflect on what they might learn from the past approaches of the Medunsa programme.

Problem-based learning (PBL) and early clinical placements (CP) are recognised as complementary strategies for developing clinical reasoning (CR) in medical education. However, how alternating between these formats influences the CR process from students’ perspectives remains underexplored. This qualitative-led exploratory mixed-methods study examined how curriculum sequencing shapes Graduate Entry Medical students’ perceptions of their CR process. Fourteen Year-2 students participated across two pre-existing streams: one began with PBL and the other with CP before switching. Across these alternating phases, students completed the Self-Assessment of Clinical Reflection and Reasoning (SACRR), applied reasoning through vignette-based single-best-answer (SBA) questions to prompt reflection on their reasoning processes. Students’ reflections were further explored through in-depth semi-structured interviews. Thematic analysis formed the primary interpretive strand, supported by descriptive quantitative data. Interview findings revealed that alternating PBL and CP encouraged students to reflect on, apply, and progressively refine their reasoning skills. Students valued the complementary relationship between classroom discussion and authentic clinical exposure, citing case-based dialogue, GP teaching, and supportive environments as key enablers, while heavy workloads, examination pressures, and over-guided PBL sessions were perceived as barriers to CR process. Overall, CR development emerged as a gradual, experiential process enhanced by the dynamic interplay of PBL and clinical learning. These findings underscore the importance of integrating structured discussion with authentic patient encounters rather than privileging one learning format or sequence over the other.

IntroductionTo ensure that pre-final year medical students at Stellenbosch University were able to resume clinical training during the COVID-19 pandemic, a 12-week integrated rotation was introduced, during which students were distributed across a widespread training platform in two provinces of South Africa, utilizing a range of health care facilities in both rural and urban areas, rather than the central academic hospital (CAH) in which they would have been doing clerkships. Called the Integrated Distributed Engagement to Advance Learning (IDEAL) rotation, this clerkship was based on supervised engagement in healthcare services, focusing on patient-based clinical training, self-regulated learning and student participation as integral members of clinical teams. The success of this emergency intervention has led to its formal incorporation into the medical curriculum. This study aimed to understand the factors that influenced learning among students undertaking the IDEAL rotation at multiple sites on a distributed training platform.MethodsUsing an interpretive paradigm, we sought to conduct focus group interviews with students who completed the first iteration of the IDEAL rotation in the year after they had undertaken it to understand their experiences. All 252 students who were eligible were invited to participate by email on several occasions. Ultimately three focus group discussions and two individual interviews were undertaken, based on volunteers. Using a semi-structured interview guide, these explored student perceptions of their learning and growth through the rotation. Inductive and deductive analysis was carried out to identify themes.FindingsStudent descriptions of their learning experiences coalesced in 6 themes. The rotation was an enabling learning experience, which was more practically focused and assisted students in developing confidence in their clinical skills. It was seen to be a humanizing learning experience with greater opportunities for the development of relationships with patients and families, as well as with health professionals, who made them feel part of the team, so it was also a more collegial learning experience. At the same time, it was a variable learning experience with a lack of standardization on a number of levels and challenges being experienced at particular sites regarding both logistics and the nature of the exposure. Students perceived it to be a very different learning experience from what they had encountered in the CAH in terms of relationships, the kinds of patients and problems they saw, and their active participation. Through this, they also learned more about themselves and their roles, making it a personal learning journey. The findings confirm the importance of the dimensions of person, participation and place for being and becoming a doctor in a clinical environment.ConclusionsStudent learning experiences in the IDEAL rotation emphasize the importance of context, reinforcing the value of a distributed training platform in developing health professionals who are responsive to their environment. They emphasize the vital role of active participation in learning and the centrality of relationships in medical training, helping to develop graduates who are human beings and not only human doings.

Introduction Globally, faculty development initiatives in support of health professions (HP) educators continue to extend their remit. This work becomes more critical as HP curriculum renewal activities are influenced by needing to move beyond a biomedical focus attending to issues such as social accountability, social justice and health equity. This raises questions about how best to support our HP educators who may need to change their teaching practice as they embrace these more complex, social constructs. Methods The research question for this qualitative study was: What implications are there for faculty development that can support HP educators as they are expected to incorporate the principles of critical consciousness and social accountability into their teaching as part of a curriculum renewal process? Data from 11 focus group discussions and 11 subsequent individual interviews with HP educators from two undergraduate programmes were thematically analysed after which further analysis focussed on the implications of these findings for faculty development. Transformative learning theory and models about change provided a sensitising framework. Results Our findings pointed to an expanded role for HP educators and consequently also for those responsible for faculty development. Three main ideas were highlighted: Curriculum renewal catalyses a renewed need for faculty development, the nature of faculty development that can enable change and new foci for faculty development. Conclusions Faculty development can make a significant contribution to enabling change, including in the context of curriculum renewal that often extends the roles and responsibilities of HP educators. When renewal seeks to shift fundamental curriculum principles, providing support to embrace this expanded remit results in an equally expanded remit for faculty developers—one that calls for initiatives that enable critical, dialogic encounters that might foster critical consciousness, leading to change in HP education. This challenges us, as faculty developers, to turn the mirror on ourselves to consider the nature of such expanded support.

BACKGROUND AND OBJECTIVES:Residents play a significant role in teaching undergraduate medical students though most residents have not received formal training in teaching and may be adopting ineffective teaching strategies. Many institutions have established a residents-as-teachers (RaT) programme to improve residents' teaching skills. However, many RaT programmes were established without a context-specific needs assessment. This study describes a need assessment survey of residents' teaching skills. The specific objectives of the study were to determine the residents' selfperceived and true learning needs for facilitating clinical teaching, the preferred important topics and methods of instruction for a RaT programme.METHODS:This cross-sectional, prospective, observational, quantitative study involved self-assessment of residents' teaching skills and assessments of those residents by medical students and an observer during actual clinical bedside teachings using the Maastricht Clinical Teaching Questionnaire.RESULTS:Thirty-nine (78%) out of 50 residents participated in the study, of which 20 agreed to direct observation of teaching. Sixty-two (85%) of the 73 medical students completed 82 evaluations of residents' teaching. The residents' self-perceived and true learning needs were in the domains of exploration, scaffolding, modelling, coaching and reflection. The leading preferred topics were communication skills, leadership, the teaching of procedural skills, and bedside teaching. The preferred methods of instruction were interactive sessions with teachers and working in small groups with a facilitator.CONCLUSIONS:Residents performed well in creating a safe learning environment but were poor in exploration, scaffolding, modelling, coaching and reflection domains of teaching. These findings will inform the design of a tailor-made RaT programme.

INTRODUCTION:The medical school selection literature comes mostly from a few countries in the Global North and offers little opportunity to consider different ways of thinking and doing. Our aim, therefore, was to critically consider selection practices and their sociohistorical influences in our respective countries (Brazil, China, Singapore, South Africa and the UK), including how any perceived inequalities are addressed. METHODS:This paper summarises many constructive dialogues grounded in the idea of he er butong () (harmony with diversity), learning about and from each other. RESULTS:Some practices were similar across the five countries, but there were differences in precise practices, attitudes and sociohistorical influences thereon. For example, in Brazil, South Africa and the UK, there is public and political acknowledgement that attainment is linked to systemic and social factors such as socio-economic status and/or race. Selecting for medical school solely on prior attainment is recognised as unfair to less privileged societal groups. Conversely, selection via examination performance is seen as fair and promoting equality in China and Singapore, although the historical context underpinning this value differs across the two countries. The five countries differ in respect of their actions towards addressing inequality. Quotas are used to ensure the representation of certain groups in Brazil and regional representation in China. Quotas are illegal in the UK, and South Africa does not impose them, leading to the use of various, compensatory 'workarounds' to address inequality. Singapore does not take action to address inequality because all people are considered equal constitutionally. DISCUSSION:In conclusion, medical school selection practices are firmly embedded in history, values, societal expectations and stakeholder beliefs, which vary by context. More comparisons, working from the position of acknowledging and respecting differences, would extend knowledge further and enable consideration of what permits and hinders change in different contexts.

Responding to the need for authentic clinical training for students in the context of coronavirus disease 2019 (COVID-19), the Stellenbosch University Faculty of Medicine and Health Sciences developed an innovative 12-week longitudinal, integrated rotation for pre-final-year medical students, the Integrated Distributed Engagement to Advance Learning (IDEAL) rotation. This saw 252 students being placed across 30 primary and secondary healthcare facilities in the Western and Northern Cape provinces. With a focus on service learning, the rotation was built on experiences and research of members of the planning team, as well as partnership relationships developed over an extended period. The focus of student learning was on clinical reasoning through being exposed to undifferentiated patient encounters and the development of practical clinical skills. Students on the distributed platform were supported by clinicians on site, alongside whom they worked, and by a set of online supports, in the form of resources placed on the learning management systems, learning facilitators to whom patient studies were submitted and wellness supporters. Important innovations of the rotation included extensive distribution of clinical training, responsiveness to health service need, co-creation of the module with students, the roles of learning facilitators and wellness supporters, the use of mobile apps and the integration of previously siloed learning outcomes. The IDEAL rotation was seen to be so beneficial as a learning experience that it has been incorporated into the medical degree on an ongoing basis.Contribution: Longitudinal exposure of students to undifferentiated patients in a primary health care context allows for integrated, self-regulated learning. This provides excellent opportunities for medical students, with support, to develop both clinical reasoning and practical skills.

Stellenbosch University embarked on a renewal of its MBChB programme guided by an updated set of core values developed by the multidisciplinary curriculum task team. These values acknowledged the important role of (among others) context and generalism in the development of our graduates as doctors of the future for South Africa. This report describes the overall direction of the renewed curriculum focusing on two of the innovative educational methods for Family Medicine and Primary Health Care training that enabled us to respond to these considerations. These innovations provide students with both early longitudinal clinical experience (now approximately 72 h per year for each of the first 3 years) and a final longitudinal capstone experience (36 weeks) outside the central tertiary teaching hospital. While the final year experience will run for the first time in 2027 (the first year launched in 2022), the initial experience has got off to a good start with students expressing the value that it brings to their integrated, holistic learning and their identity formation aligned with the mission statement of this renewed curriculum. These two curricular innovations were designed on sound educational principles, utilising contextually appropriate research and by aligning with the goals of the healthcare system in which our students would be trained. The first has created opportunities for students to develop a professional identity that is informed by a substantial and longitudinal primary healthcare experience. Contribution: The intention is to consolidate this in their final district-based experience under the supervision of specialist family physicians and generalist doctors.

"Response to: 'Commentary on the AMEE guide to selection into medical school'." Medical Teacher, ahead-of-print(ahead-of-print), p. 1 Disclosure statementFiona Patterson is a Director for Work Psychology Group Ltd, a consulting practice that provides advice on selection methodologies (such as SJTs, interviews, aptitude tests, knowledge tests, and selection centres). The other authors declare that they have no competing interests.Data availability statementFull references for work referred to in the text available on request from the authors.Additional informationFundingThe author(s) reported there is no funding associated with the work featured in this article.

OBJECTIVES:Many universities offer faculty development to support teachers in developing and improving clinical education in the health professions. Although research shows outcomes on individual levels after faculty development, little is known about its contribution to change within the organisation. To advance current faculty development and ensure that it can support wider educational change in healthcare organisations, a better understanding of educational change practices in these settings is needed. This study therefore explores the experiences of working with educational change in clinical workplaces from the perspective of clinical educators that have undergone faculty development training. The study adopts perspectives on change as influenced by context to include the impact from clinical workplaces on individuals' change work.METHODS:A collective case study design with a multi-institutional approach was applied and individual interviews with 14 clinical educators from two universities, one in Sweden and one in South Africa, were conducted. Data were analysed separately before a cross-case analysis was performed, synthesising the findings from both sites.FINDINGS:Participants shared experiences of having limited opportunities to work with educational change beyond their own individual teaching practices within their clinical workplaces. Also, participants appeared to refrain from leading change and rather pursued change on their own or relied on indirect approaches to change. They described several workplace aspects influencing their work, including the organisation and management of teaching, the resources and incentives for teaching and the attitudes and beliefs about teaching within the clinical community.CONCLUSIONS:The study shows that clinical educators are part of communities and contexts that shape their approaches to educational change and influence which changes are feasible and which ones are not. It thus adds to the understanding of change as contextual and dynamic and contributes with implications for how to advance faculty development to better support change in practice.

Global health inequities have created an urgency for health professions education to transition towards responsive and contextually relevant curricula. Such transformation and renewal processes hold significant implications for those educators responsible for implementing the curriculum. Currently little is known about how health professions educators across disciplines understand a responsive curriculum and how this understanding might influence their practice. We looked at curricula that aim to deliver future health care professionals who are not only clinically competent but also critically conscious of the contexts in which they serve and the health care systems within which they practice. We conducted a qualitative study across six institutions in South Africa, using focus group discussions and in-depth individual interviews to explore (i) how do health professions educators understand the principles that underpin their health professions education curriculum; and (ii) how do these understandings of health professions educators shape their teaching practices? The transcripts were analysed thematically following multiple iterations of critical engagement to identify patterns of meaning across the entire dataset. The results reflected a range of understandings related to knowing, doing, and being and becoming; and a range of teaching practices that are explicit, intentionally designed, take learning to the community, embrace a holistic approach, encourage safe dialogic encounters, and foster reflective practice through a complex manner of interacting. This study contributes to the literature on health professions education as a force for social justice. It highlights the implications of transformative curriculum renewal and offers insights on how health professions educators embrace notions of social responsiveness and health equity to engage with these underlying principles within their teaching.

For experiential learning to be transformative for students, the clinical educator must create authentic practice-based participation which uses prior knowledge to build competence. Encouraging student agency for their own learning, whilst engaging in social interactions that foster constructive feedback, leads to reflective learning and achieving the intended learning outcomes.

Introduction Systematic and structural inequities in power and privilege create differential attainment whereby differences in average levels of performance are observed between students from different socio-demographic groups. This paper reviews the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research. Methods Authors first identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment related to ethnicity/race in medical education and, where available and relevant, literature from higher education more generally. Each author then conducted a review of the literature and proposed guidelines based on their experience and research literature. The guidelines were iteratively reviewed and refined between all authors until we reached consensus on the Do’s, Don’ts and Don’t Knows. Results We present 13 guidelines with a summary of the research evidence for each. Guidelines address assessment practices (assessment design, assessment formats, use of assessments and post-hoc analysis) and educational systems and cultures (student experience, learning environment, faculty diversity and diversity practices). Conclusions Differential attainment related to ethnicity/race is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school. Currently, the strongest empirical evidence is around assessment processes themselves. There is emerging evidence of minoritized students facing discrimination and having different learning experiences in medical school, but more studies are needed. There is a pressing need for research on how to effectively redress systemic issues within our medical schools, particularly related to inequity in teaching and learning.

South Africa has an obligation to redress historical inequitable access to medical education. A variety of strategies have been used to both widen access as well as to increase the number of places in medical school; however, possibly uniquely in the world, the majority ethnic group in the country remains underrepresented in medicine. While we may be on track to addressing equality in terms of offering everyone the same access to a place in medical school, the challenge now is to address equity, in other words to recognise that not all students start from the same place and that medical schools must therefore acknowledge and make adjustments to imbalances. This needs to be an ongoing process, requiring us to identify and overcome intentional and unintentional barriers arising from bias and systemic structures. If we accept that learning is socially constructed, we see that anything that impacts, or is impacted by, the social has a consequence for learning. Learning theories and the medical education literature assist us in thinking about this—social cognitive learning (Bandura), transformative learning (Mezirow), situated learning (Wenger), growth mindset (Dweck), feedback literacy (Carless), and relational pedagogy (Hinsdale) among others, in particular how these play out in clinical learning where competence depends on learning in context (Eraut), authentic and structured vocational activities with the guidance of more expert others (Billett), and experience-based learning (Dornan). Internationally, we see that in clinical environments, students suffer microaggressions, are subject to minority tax, and may experience shame triggers and promoters (Bynum 2020). Our own research conducted at Stellenbosch University showed that for final year medical students, there was a tension between expecting to be invited to participate in clinical work but not necessarily experiencing that. Students did not always have a sense of agency to ask to participate (Blitz, 2019). Participation requires a sense of belonging. “Fitting in is about assessing a situation and becoming who you need to be to be accepted. Belonging, on the other hand, doesn't require us to change who we are; it requires us to be who we are” (Brown, 2010). So, how do organisations enable all students and staff to “be who they are”? The Macy Foundation (2020) suggests three important responses to addressing harmful bias, one of which relates to “culture change.” This includes training (response to microaggressions, being an upstander/ally, and anti-racism), but also requires “institutional response to discriminatory behaviours.” In a piece in the “When I say …” series, we stated that rather than “doing diversity,” we aligned ourselves with diversity as an explicit value position—excellence in medical education and practice can only truly occur once historical obstacles are recognised and addressed, and the notions of belonging, inclusion and virtue in difference are authentically embraced. Ultimately, diversity efforts must be directed at “recalibrating” the system (Chiavarolli, 2020). The majority group is privileged and as a manifestation of its power offers “others” (those who are different from them in a critical way) an opportunity to be represented in the majority group. However, when confronted by the realities of these “others,” members of the dominant cultural group tend to have a defensive, wounded, angry, or dismissive response—referred to as fragility. Our fragility should not prevent us from having courageous conversations about change. These discussions are not easy, but avoidance is even worse. As we prepare ourselves, we should heed the advice to stay engaged, expect to experience discomfort, encourage all to speak their truth, and expect and accept a lack of closure. Those with power and privilege have the capacity to change the culture. Is attending to the social learning environment the current “big ask”? Should teachers be encouraged and assisted to engage in courageous conversations with each other and with students? The title of this conference was “Disrupted Medical Education - challenging the norms of medical education.” Disruption requires vulnerability. Are we, in medical education organisations and institutions, willing to be vulnerable and engage in real cultural change? I would like to remind us of Representative John Lewis' phrase “Never, ever be afraid to make some noise and get in good trouble, necessary trouble.” Widening participation was a necessary initial step, but now we need to work towards full participation. Here's to “making some good trouble” as we disrupt our norms to not just widen selection, but to nurture truly full participation.

Background There is a global trend towards providing training for health professions students outside of tertiary academic complexes. In many countries, this shift places pressure on available sites and the resources at their disposal, specifically within the public health sector. Introducing an educational remit into a complex health system is challenging, requiring commitment from a range of stakeholders, including national authorities. To facilitate the effective implementation of distributed training, we developed a guiding framework through an extensive, national consultative process with a view to informing both practice and policy. Methods We adopted a participatory action research approach over a four year period across three phases, which included seven local, provincial and national consultative workshops, reflective work sessions by the research team, and expert reviews. Approximately 240 people participated in these activities. Engagement with the national department of health and health professions council further informed the development of the Framework. Results Each successive ‘feedback loop’ contributed to the development of the Framework which comprised a set of guiding principles, as well as the components essential to the effective implementation of distributed training. Analysis further pointed to the centrality of relationships, while emphasising the importance of involving all sectors relevant to the training of health professionals. A tool to facilitate the implementation of the Framework was also developed, incorporating a set of ‘Simple Rules for Effective distributed health professions training’. A national consensus statement was adopted. Conclusions In this project, we drew on the thinking and practices of key stakeholders to enable a synthesis between their embodied and inscribed knowledge, and the prevailing literature, this with a view to further enaction as the knowledge generators become knowledge users. The Framework and its subsequent implementation has not only assisted us to apply the evidence to our educational practice, but also to begin to influence policy at a national level.

The Clinical TeacherVolume 17, Issue 5 p. 541-543 Covid-19 Insights Teaching clinical reasoning: a new playbook Susan van Schalkwyk, Corresponding Author Susan van Schalkwyk scvs@sun.ac.za orcid.org/0000-0003-1596-6791 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaCorresponding author's contact details: Susan van Schalkwyk, Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa. E-mail: scvs@sun.ac.zaSearch for more papers by this authorElize Archer, Elize Archer orcid.org/0000-0002-9739-3730 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaSearch for more papers by this authorMariette Volschenk, Mariette Volschenk orcid.org/0000-0003-4516-5143 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaSearch for more papers by this authorJulia Blitz, Julia Blitz orcid.org/0000-0001-5229-3907 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaSearch for more papers by this author Susan van Schalkwyk, Corresponding Author Susan van Schalkwyk scvs@sun.ac.za orcid.org/0000-0003-1596-6791 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaCorresponding author's contact details: Susan van Schalkwyk, Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa. E-mail: scvs@sun.ac.zaSearch for more papers by this authorElize Archer, Elize Archer orcid.org/0000-0002-9739-3730 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaSearch for more papers by this authorMariette Volschenk, Mariette Volschenk orcid.org/0000-0003-4516-5143 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaSearch for more papers by this authorJulia Blitz, Julia Blitz orcid.org/0000-0001-5229-3907 Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South AfricaSearch for more papers by this author First published: 28 July 2020 https://doi.org/10.1111/tct.13231 Funding: None. Conflict of interest: None. Acknowledgement: The authors wish to thank Kanita Brits, who contributed to the development of the template. Ethical approval: Not required. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume17, Issue5October 2020Pages 541-543 RelatedInformation

Health Professions Education (HPE) curricula have a dual purpose: to deliver professionals who are clinically competent and critically conscious of the contexts and health systems they serve. This qualitative study advances a social justice agenda by exploring the range of understandings that HPE teachers have of this dual purpose of their curricula. Thirty-four respondents participated in eleven focus groups and eleven interviews. Data were analysed thematically. While participants understood this dual purpose of their curricula, some felt that clinical competence should be emphasised above critical consciousness. Implementing curricula that develop critically conscious graduates raises questions about what counts as knowledge, and about how far our responsibility extends in preparing students to become change agents. This has implications for the role and identity of the HPE teacher and points to a re-envisioning of the process of curriculum development and the role that HPE centres play in the process of curriculum development.

The authors explore the meanings, significance, implications of the term ‘diversity’, arguing this crucial concept needs to be understood contextually, critically.