The dual goals of medical training are to ensure that trainees can demonstrate the performance required to move on to the next phase of their training while, at the same time, shaping "nonability" outcomes that should support lifelong learning and improve performance over time. Yet, the data on performance after completion of training suggest that we are not consistently meeting our second goal. Here, the authors consider nonability outcomes as a composite of 3 overlapping attributes: mindset; motivation; and grit, and use the term "growth attributes" to describe this composite outcome. Because learning experiences typically involve at least 1 teacher, they view the impact of learning experiences on outcomes as a person × person × context (P × P × C) interaction. They review relevant literature on the impact of growth attributes on future learning and use the P × C × C framework to discuss potential strategies to enhance 1 or more growth attributes in medical trainees. The authors predict that changes to the learning context that promote educational safety and trainee autonomy should support growth attributes. Similarly, the interaction between trainee and teacher is likely to cultivate growth attributes when the teacher balances support of the trainee with an appropriate level of challenge, provides growth-promoting feedback, and models growth attributes. In addition to potentially improving lifelong learning and future clinical performance, growth attributes may bring additional benefits to trainees and physicians in the form of enhanced well-being and reduced risk of burnout. Consequently, growth attributes can be viewed as a surrogate for important long-term outcomes. The authors end by proposing future steps for exploring the role of growth attributes in medical training, starting with a validity evaluation of tools to assess growth attributes followed by studies to evaluate strategies to nurture growth attributes in medical trainees.

Background and Aims Endoscopic mucosal resection (EMR) is not systematically taught during most training programs. The aim of this study was to evaluate the effectiveness and clinical utility of a 1-day didactic and simulation-based EMR curriculum for practicing endoscopists without prior formal training in advanced endoscopic tissue resection. Methods We designed a 1-day lecture and simulation-based EMR course. Twelve participants completed the course. Effectiveness and clinical utility were evaluated using sequential explanatory mixed methods. All participants completed a pre-course multiple choice question (MCQ) examination followed by a separate, post-course MCQ examination with a similar blueprint. A survey was also conducted to assess cognitive fatigue, perceived benefit, and potential for change in EMR practice. Finally, a delayed MCQ examination was administered 10-14 weeks later to assess knowledge retention and qualitative data were sequentially collected from 3 candidates via semi-structured interviews. Results The mean pre-course score was 47.8% (SD 12.4%). The mean post-course score was 75% (9.9%) and the mean delayed score was 70.8% (13.6%), both significantly higher than the mean pre-course score (P < .001; Cohen’s d = 1.86 and P < .001; Cohen’s d = 1.47, respectively). There was no significant difference between the mean post- and delayed-course test scores (P = .2). Three themes emerged from the interviews: (1) a need for EMR training, (2) improved knowledge evaluating polyps, and (3) changed or refined EMR technique after the course. Conclusions This study demonstrates significant knowledge acquisition and retention of cognitive skills and suggests a change in practice following a 1-day focused didactic and simulation-based EMR course.

Group decision-making is now common in medical education, often used for decisions that are both complex and high stakes, such as determining whether to promote or remediate a trainee. In this context, it is often assumed that group decision making is superior to that of an individual, resulting in high quality decision outcomes through the pooling of collective knowledge and experience. Yet, while groups can outperform individuals, this is not guaranteed. In fact, groups are vulnerable to several cognitive biases and process issues that individuals are not subject to and these can lead to poor quality decision outcomes if not managed. As educational leaders who participate in group decision-making, we believe it is our responsibility to ensure the quality of these complex and high-stakes decisions. In this article, we discuss both the potential benefits and vulnerabilities of group decision-making by introducing the concepts of wisdom of the crowd and groupthink, respectively. With this foundation, we then offer twelve evidence-based tips that can be easily implemented in educational group decision-making to minimize groupthink and leverage the wisdom of the crowd.

Mentorship is recognized as beneficial to the personal and professional development of physicians. It has been shown to positively influence career success and research productivity for the mentee, while being associated with increased job satisfaction and lower risk of burnout for the mentor. At an institutional level, when aligned with strategic priorities, mentorship can facilitate gender and racial equality, and improve faculty retention. Consequently, there are calls to prioritize and formalize mentorship, yet the optimal way to achieve this remains elusive. How exactly do we create a mentorship program that is viewed as effective from the perspective of the mentor, mentee, and the institution? In this article we approach mentorship as a complex system, and through this lens we aim to provide medical educators and leaders with guidance on how to create and evaluate a program that provides mentees with distributed and precision mentoring, while also aligning with institutional priorities.

Health Professional Education (HPE) programmes, such as mentorship, are widely regarded as being advantageous to the personal and professional development of clinicians and trainees. Involvement in a mentoring relationship is associated with positive outcomes for both mentees and mentors, including improved career preparation, increased career success, higher job satisfaction and reduced risk of burnout. Despite these data, a minority of trainees report having a mentor. In this Cross-Cutting Edge article, the authors focus on an impediment to participation in HPE programmes that they feel are both highly prevalent and modifiable: habit. Taking the example of mentorship, they use dual processing as their theoretical framework and describe how we use both System 1 and System 2 processing to make decisions that, in turn, promote habitual and goal-directed actions, respectively. The authors discuss the relationship between habitual and goal-directed actions and suggest that habits can both facilitate and hinder our goals. Drawing on the clinical literature on adherence to clinical practice guidelines, they describe how habits and contextual factors can interfere with clinical goals and how manipulating the clinical environment can move behaviour in the desired direction. They then branch into behavioural economics to describe the features of a nudge (and a sludge) and review the literature on the effectiveness of this type of intervention - including potential ethical concerns around the use of nudges as behavioural interventions. Using the MINDSPACE mnemonic/framework they suggest different types of transparent and non-transparent nudges that could be used to increase participation in mentorship. Recognizing that mentorship is complex and the impact of a single nudge on behaviour may be ineffective or wane over time, the authors propose a process of ongoing programme evaluation and quality improvement that could help create and maintain a culture of mentorship and that can also be applied to other HPE programmes.

Mentorship is now recognized as essential to the personal and professional development of physicians. Over the past decade, it has become a common theme in medical education literature, and through this our understanding of mentorship has evolved. Despite this progress, we believe that the prevailing reductionist view of mentorship is oversimplified and may hinder further advances in this space. Instead, we propose that mentorship be viewed through the lens of complexity theory, positioning it as a prototypical complex adaptive system. This shift in perspective will inform our mentorship interventions and evaluations, and can avoid the disappointment that invariably follows when we apply a simple approach to a complex situation.

Background In 2015, the Medical Council of Canada increased the minimum pass level for the Medical Council of Canada Qualifying Examination Part I, and students had a higher rate of failure than in previous years. The purpose of this study was to predict students at an increased odds of examination failure to allow for early, targeted interventions. Methods We divided our dataset into a derivation cohort and two validation cohorts and used multiple logistic regression to predict licensing examination failure. We then performed receiver operating characteristics and a sensitivity analysis using different cutoffs for explanatory variables to identify the cutoff threshold with the best predictive value at identifying students at increased odds of failure. Results: After multivariate analysis, only pre-clerkship GPA was a significant independent predictor of failure (OR 0.76, 95% CI [0.66, 0.88], p < 0.001). The probability of failure increased steeply when the pre-clerkship GPA fell below 80% and 76% was found to be the most efficient cutoff for predicting failure (OR 9.37, 95% CI [3.08, 38.41]). Conclusions: Pre-clerkship performance can predict students at increased odds of licensing examination failure. Further studies are needed to explore whether early interventions for at-risk students alter their examination performance.

Purpose To describe how the authors developed an objective structured clinical examination (OSCE) station to assess aspects of collaborative practice competency and how they then assessed validity using Kane’s framework. Method After piloting the collaborative practice OSCE station in 2015 and 2016, this was introduced at the Cumming School of Medicine in 2017. One hundred fifty-five students from the class of 2017 and 22 students from the class of 2018 participated. To create a validity argument, the authors used Kane’s framework that views the argument for validity as 4 sequential inferences on the validity of scoring, generalization, extrapolation, and implications, Results Scoring validity is supported by psychometric analysis of checklist items and the fact that the contribution of rater specificity to students’ ratings was similar to OSCE stations assessing clinical skills alone. The claim of validity of generalization is backed by structural equation modeling and confirmatory factor analysis that identified 5 latent variables, including 3 related to collaborative practice (“provides an effective handover,” “provides mutual support,” and “shares their mental model”). Validity of extrapolation is argued based upon the correlation between the rating for “shares their mental model” and the rating on in-training evaluations for “relationship with other members of the health care team,” in addition to the association between performance on the collaborative practice OSCE station and the subsequent rating of performance during residency. Finally, validity of implications is supported by the fact that pass/fail decisions on the collaborative practice station were similar to other stations and by the observation that ratings on different aspects of collaborative practice associate with pass/fail decisions. Conclusions Based upon the validity argument presented, the authors posit that this tool can be used to assess the collaborative practice competence of graduating medical students and the adequacy of training in collaborative practice.

Background Research on the predictive validity of the Medical College Admissions Test (MCAT) on licensing examination performance is varied in its conclusions, with only a few studies examining this relationship in a Canadian context. We assessed the predictive validity of the MCAT on successful performance on the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 by students attending the Cumming School of Medicine. Methods Prospective data were collected on MCAT score and sub-section scores, MCCQE decision, multiple mini interview (MMI) performance, gender, and age. The cohort was divided into a derivation cohort (2013 and 2014) and validation cohort (2015 and 2016). Students were dichotomized into pass or fail on MCCQE. Multiple logistic regression in which our dependent variable was MCCQE Part I examination success at the first attempt was used, and potential explanatory variables were age, gender, MCAT total score, and sub-scores for the biological sciences (MCAT-BS), physical sciences, and verbal reasoning, GPA, and MMI ratings. Results For the derivation cohort MCAT-BS was associated with success on the MCCQE Part I. The odds ratio for this association of 1.37 (95% confidence interval [1.01, 1.85], p = 0.04). When we applied the MCAT-BS to our validation cohort the odds ratio of MCCQE Part I examination success was 1.42 [1.10, 1.83], p = 0.007) and the area under the ROC curve was 0.66 [0.54, 0.79]). Conclusion The MCAT-BS predicted successful performance on the MCCQE Part 1 Examination in the Canadian setting.

Advances in computer visualization enabling both 2D and 3D representation have generated tools to aid perception of spatial relationships and provide a new forum for instructional design. A key knowledge gap is the lack of understanding of how the brain neurobiologically processes and learns from spatially presented content, and new quantitative variables are required to address this gap. The objective of this study was to apply quantitative neural measures derived from electroencephalography (EEG) to examine stereopsis in anatomy learning by comparing mean amplitude changes in N250 (related to object recognition) and reward positivity (related to responding to feedback) event related to potential components using a reinforcement-based learning paradigm. Health sciences students (n = 61) learned to identify and localize neuroanatomical structures using 2D, 3D, or a combination of models while EEG and behavioral (accuracy) data were recorded. Participants learning using 3D models had a greater object recognition (N250 amplitude) compared to those who learned from 2D models. Based on neurological results, interleaved learning incorporating both 2D and 3D models provided an advantage in learning, retention, and transfer activities represented by decreased reward positivity amplitude. Behavioral data did not have the same sensitivity as neural data for distinguishing differences in learning with and without stereopsis in these learning activities. Measuring neural activity reveals new insights in applied settings for educators to consider when incorporating stereoscopic models in the design of learning interventions.

Technological advances enabling presentation of content stereoscopically provide a new forum for instructional design in anatomy education that instructors are keen to explore. Studies comparing the effectiveness of learning from two‐dimensional (2D) versus three‐dimensional (3D) visualizations are limited by sole reliance on behavioural evidence like learner preferences and test performance. Though it is reasonable to assume that student performance on knowledge‐based tests is indicative of success, these tests fail to illuminate the subtleties of a learner's interaction with visualization tools in the process of learning. Quantitative measurement of the learning process through direct monitoring of neural processes offers an alternative means of assessment to compare learning 2D and 3D learning in anatomy. Frequency band oscillation activity measured by electroencephalography (EEG) may give direct insight into cognitive resources required during a learning task. Medial frontal theta (MFT) oscillations (4–8 Hz) have been shown to increase with increased working memory requirements. The aim of this study was to compare MFT neural activity as measured by EEG as participants learn from 2D versus 3D anatomical visualizations. MFT activity was compared as novice participants (n = 21) learned to identify and localize neuroanatomical structures using a reinforcement‐based learning paradigm. Participants learned from neuroanatomical models that were presented both with and without stereoscopic disparity using NVIDIA 3D Vision® 2 goggles while EEG data were collected. Data were processed using Brain Vision Analyzer 2 software and statistical analysis was performed using SPSS statistics. This study was approved by the Conjoint Health Research Ethics Board at the University of Calgary (Ethics ID: REB14‐088). We found that MFT was greater when participants were viewing 3D models compared to 2D models (p < .05), indicating that greater working memory engagement is required to view 3D models. In the context of cognitive load theory (CLT), these findings are important for educators. If students are participating in a learning activity that uses 3D models (which requires greater working memory resources), then less free capacity remains in the total working memory to engage with the learning activity itself. Therefore when educators are designing learning activities that use 3D models, activities may have to be simplified or use techniques that promote germane load as a compensatory strategy to ensure successful learning.Support or Funding InformationThis research was supported by University of Calgary grants (competitive) awarded to the authors including: Teaching and Learning Grant; University Research Grants Committee (URGC) Seed Grant; and the Data and Technology Fund. SA would like to acknowledge scholarship funding provided by: Social Sciences and Humanities Research Council (SSHRC) Doctoral Fellowship; Alberta Innovates Health Solutions (AIHS) Graduate Studentship, and the Queen Elizabeth II Graduate Doctoral Scholarship.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Aims: To describe potential sources of bias during an academic assessment reappraisal and ways to mitigate these. Methods: We describe why the typical scenario of an academic assessment reappraisal - where committee members are asked to weigh contrasting accounts of past events that they did not witness, and to rate elusive constructs, such as "fairness" - is prone to multiple types of bias, including attribute substitution, default bias, confirmation bias, and impact bias. We also discuss how increased awareness of sources of bias and of debiasing strategies can improve the validity of decision making. Results: Strategies that can reduce bias in reappraisal include clearly articulating and focusing on the reappraisal question (did bias cause a wrong decision to be made?), educating those involved in the reappraisal of the types of bias that frequently occur in teaching and assessment (including biases that they themselves may introduce to the reappraisal), and ensuring that those involved in the reappraisal contribute equally to making decisions and recommendation. Conclusions: All academic assessments of students, particularly those that involve subjective ratings of performance, are prone to bias, which threatens the integrity of the assessment process. Given the high stakes of academic assessments, we feel that each medical school should have a process for assessment reappraisal that reduces, rather than compounds, the likelihood of wrong assessment decisions.

In this article, we question if and why the Canadian national medical education organizations have failed to introduce or promote changes that compel or encourage Canadian medical schools to heed the recommendation from the Future of Medical Education in Canada report to "build on the scientific basis of medicine." We end by offering suggestions on how these organizations could help Canadian medical schools build in the scientific basis of medicine.

Prior studies have shown a correlation between the grades students receive and how they rate their teacher in the classroom. In this study, the authors probe this association on clinical rotations and explore potential mechanisms. All In-Training Evaluation Reports (ITERs) for students on mandatory clerkship rotations from April 1, 2013 to January 31, 2015 were matched with the corresponding student’s rating of their teacher (SRT). The date and time that ITERs and SRTs were submitted was used to divide SRTs into those submitted before versus after the corresponding ITER was submitted. Multilevel, mixed effects linear regression was used to examine the association between SRT, ITER rating, and whether the ITER was submitted before or after SRT. Of 2373 paired evaluations, 1098 (46.3%) SRT were submitted before the teacher had submitted the ITER. There was a significant interaction between explanatory variables: when ITER ratings had not yet been submitted, the regression coefficient for this association was 0.25 (95% confidence interval [0.17, 0.33], p < 0.001), whereas the regression coefficient was significantly higher when ITER ratings were submitted prior to SRT (0.40 [0.31, 0.49], p < 0.001). Finding an association between SRT and ITER when students do not know their ITER ratings suggests that SRTs can capture attributes of effective teaching, but the effect modification when students have access to their ITER rating supports grade satisfaction bias. Further studies are needed to explain the mechanism of grade satisfaction and to identify other biases that may impact the validity of SRT.

After many years in the making, an increasing number of postgraduate medical education (PGME) training programs in North America are now adopting a competency-based medical education (CBME) framework based on entrustable professional activities (EPAs) that, in turn, encompass a larger number of competencies and training milestones. Following the lead of PGME, CBME is now being incorporated into undergraduate medical education (UME) in an attempt to improve integration across the medical education continuum and to facilitate a smooth transition from clerkship to residency by ensuring that all graduates are ready for indirect supervision of required EPAs on day one of residency training. The Association of Faculties of Medicine of Canada recently finalized its list of 12 EPAs, which closely parallels the list of 13 EPAs published earlier by the Association of American Medical Colleges, and defines the “core” EPAs that are an expectation of all medical school graduates. In this article, the authors focus on important, practical considerations for the transition to CBME that they feel have not been adequately addressed in the existing literature. They suggest that the transition to CBME should not threaten diversity in UME or require a major curricular upheaval. However, each UME program must make important decisions that will define its version of CBME, including which terminology to use when describing the construct being evaluated, which rating tools and raters to include in the assessment program, and how to make promotion decisions based on all of the available data on EPAs.

Despite the fact that the length of medical school training has remained stable for many years, the expectations of graduating medical students (and the schools that train them) continue to increase. In this Reflection , the authors discuss motives for educational inflation and suggest that these are likely innocent, well-intentioned, and subconscious—and include both a propensity to increase expectations of ourselves and others over time, and a reluctance to reduce training content and expectations. They then discuss potential risks of educational inflation, including reduced emphasis on core knowledge and clinical skills, and adverse effects on the emotional, psychological, and financial wellbeing of students. While acknowledging the need to change curricula to improve learning and clinical outcomes, the authors proffer that it is naïve to assume that we can inflate educational expectations at no additional cost. They suggest that before implementing and/or mandating change, we should consider of all the costs that medical schools and students might incur, including opportunity costs and the impact on the emotional and financial wellbeing of students. They propose a cost-effectiveness framework for medical education and advocate prioritization of interventions that improve learning outcomes with no additional costs or are cost-saving without adversely impacting learning outcomes. When there is an additional cost for improved learning outcomes or a decline in learning outcomes as a result of cost saving interventions, they suggest careful consideration and justification of this trade-off. And when there are neither improved learning outcomes nor cost savings they recommend resisting the urge to change.

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise.

Purpose The multiple mini-interview (MMI) improves reliability and validity of medical school interviews, and many schools have introduced this in an attempt to select individuals more skilled in communication, critical thinking, and ethical decision making. But every change in the admissions process may produce unintended consequences, such as changing intake demographics. In this article, two studies exploring gender differences in MMI ratings are reported. Method Cumulative meta-analysis was used to compare MMI ratings for female and male applicants to the University of Calgary Cumming School of Medicine between 2010 and 2014. Multiple linear regression was then performed to explore gender differences in MMI ratings after adjusting for other variables, followed by a sensitivity analysis of the impact of varying the weight given to MMI ratings on the odds of females being ranked in the top 150 applicants for 2014. Results Females were rated higher than male applicants (standardized mean difference 0.21, 95% CI [0.11, 0.30], P < .001). After adjusting for other explanatory variables, there was a positive association between female applicant and MMI rating (regression coefficient 0.23 [0.14, 0.33], P < .001). Increasing weight assigned to MMI ratings was associated with increased odds of females being ranked in the top 150 applicants. Conclusions In this single-center study, females were rated higher than males on the MMI, and the odds of a female applicant being offered a position increased as more weight was given to MMI ratings. Further studies are needed to confirm and explain gender differences in MMI ratings.