Publications by authors named "Meredith Young"

109 Publications

From What We Are Doing to Why: Describing RIME's Core Values.

Acad Med 2022 Aug 9. Epub 2022 Aug 9.

Z. Zaidi is immediate past chair, Research in Medical Education (RIME) Program Planning Committee, and professor, George Washington School of Medicine and Health Sciences, Washington, DC; ORCID: https://orcid.org/0000-0003-4328-5766.

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http://dx.doi.org/10.1097/ACM.0000000000004901DOI Listing
August 2022

Can I Ask a Question About URiM Awards That I Don't Know the Answer to? Designing an Award for Underrepresented Medical Education Researchers.

Acad Med 2022 Aug 9. Epub 2022 Aug 9.

K.A. LaDonna is assistant professor, Department of Innovation in Medical Education & Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Meaningful Equity, Diversity, and Inclusion (EDI) efforts may be stymied by concerns about whether proposed initiatives are performative or tokenistic. The purpose of this project was to analyze discussions by the Research in Medical Education (RIME) Program Planning committee about how best to recognize and support under-represented in medicine (URiM) researchers in medical education to generate lessons learned that might inform local, national, and international actions to implement meaningful Equity, Diversity, and Inclusion initiatives. Ten RIME Program Planning Committee members and administrative staff participated in a focus group held virtually in August 2021. Focus group questions elicited opinions about if and how to establish an underrepresented in medicine research award. The focus group was recorded, transcribed, and thematically analyzed. Recognition of privilege, including who has it and who doesn't, underpinned the focus group discussion, which revolved around 2 themes: (1) tensions between optics and semantics, and (2) potential unintended consequences of trying to level the medical education playing field. The overarching storyline threaded throughout the focus group discussion was intentionality. Focus group participants sought to avoid performativity by creating an award that would be meaningful to recipients and to career gatekeepers such as department chairs and promotion and tenure committees. Ultimately, participants decided to create an award that focused on exemplary EDI scholarship, which was eventually named the "RIME URiM Research Award." Difficult but productive conversations about EDI initiatives are necessary to advance URiM scholarship. This transparent commentary may trigger further critical conversations.
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http://dx.doi.org/10.1097/ACM.0000000000004902DOI Listing
August 2022

Coordinating Flight Paths to Facilitate Inter-Organizational Cooperation, Interdependence, and Autonomy: Considerations for Organizations Supporting Medical Education Research and Scholarship.

Acad Med 2022 Aug 9. Epub 2022 Aug 9.

N.J. Borges is chair-elect, Medical Education Scholarship, Research Evaluation (MESRE), and chair and professor, Department of Medical Education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; ORCID: http://orcid.org/0000-0003-0167-2725.

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http://dx.doi.org/10.1097/ACM.0000000000004915DOI Listing
August 2022

Validity as a social imperative: users' and leaders' perceptions.

Can Med Educ J 2022 Jul 6;13(3):22-36. Epub 2022 Jul 6.

Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Québec, Canada.

Introduction: Recently, was proposed as an emerging conceptualization of validity in the assessment literature in health professions education (HPE). To further develop our understanding, we explored the perceived acceptability and anticipated feasibility of validity as a social imperative with users and leaders engaged with assessment in HPE in Canada.

Methods: We conducted a qualitative interpretive description study. Purposeful and snowball sampling were used to recruit participants for semi-structured individual interviews and focus groups. Each transcript was analyzed by two team members and discussed with the team until consensus was reached.

Results: We conducted five focus group and eleven interviews with two different stakeholder groups (users and leaders). Our findings suggest that the participants perceived the concept of validity as a social imperative as acceptable. Regardless of group, participants shared similar considerations regarding: the limits of traditional validity models, the concept's timeliness and relevance, the need to clarify some terms used to characterize the concept, the similarities with modern theories of validity, and the anticipated challenges in applying the concept in practice. In addition, participants discussed some limits with current approaches to validity in the context of workplace-based and programmatic assessment.

Conclusion: Validity as a social imperative can be interwoven throughout existing theories of validity and may represent how HPE is adapting traditional models of validity in order to respond to the complexity of assessment in HPE; however, challenges likely remain in operationalizing the concept prior to its implementation.
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http://dx.doi.org/10.36834/cmej.73518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9297243PMC
July 2022

RIME Review Process: Unique Challenges and Opportunities.

Acad Med 2022 Jun 28. Epub 2022 Jun 28.

professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania.

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http://dx.doi.org/10.1097/ACM.0000000000004795DOI Listing
June 2022

Comparison of 6-month outcomes of sepsis versus non-sepsis critically ill patients receiving mechanical ventilation.

Crit Care 2022 06 13;26(1):174. Epub 2022 Jun 13.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.

Background: Data on long-term outcomes after sepsis-associated critical illness have mostly come from small cohort studies, with no information about the incidence of new disability. We investigated whether sepsis-associated critical illness was independently associated with new disability at 6 months after ICU admission compared with other types of critical illness.

Methods: We conducted a secondary analysis of a multicenter, prospective cohort study in six metropolitan intensive care units in Australia. Adult patients were eligible if they had been admitted to the ICU and received more than 24 h of mechanical ventilation. There was no intervention.

Results: The primary outcome was new disability measured with the WHO Disability Assessment Schedule 2.0 (WHODAS) 12 level score compared between baseline and 6 months. Between enrollment and follow-up at 6 months, 222/888 (25%) patients died, 100 (35.5%) with sepsis and 122 (20.1%) without sepsis (P < 0.001). Among survivors, there was no difference for the incidence of new disability at 6 months with or without sepsis, 42/106 (39.6%) and 106/300 (35.3%) (RD, 0.00 (- 10.29 to 10.40), P = 0.995), respectively. In addition, there was no difference in the severity of disability, health-related quality of life, anxiety and depression, post-traumatic stress, return to work, financial distress or cognitive function.

Conclusions: Compared to mechanically ventilated patients of similar acuity and length of stay without sepsis, patients with sepsis admitted to ICU have an increased risk of death, but survivors have a similar risk of new disability at 6 months. Trial registration NCT03226912, registered July 24, 2017.
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http://dx.doi.org/10.1186/s13054-022-04041-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9189265PMC
June 2022

When I say…response process validity evidence.

Med Educ 2022 Sep 15;56(9):878-880. Epub 2022 Jun 15.

Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal, Québec, Canada.

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http://dx.doi.org/10.1111/medu.14853DOI Listing
September 2022

It's Not Just the Prices: Time-Driven Activity-Based Costing for Initiation of Veno-Venous Extracorporeal Membrane Oxygenation at Three International Sites-A Case Review.

Anesth Analg 2022 Jun 1. Epub 2022 Jun 1.

Harvard Business School, Boston, Massachusetts.

The United States spends more for intensive care units (ICUs) than do other high-income countries. We used time-driven activity-based costing (TDABC) to analyze ICU costs for initiation of veno-venous extracorporeal membrane oxygenation (VV ECMO) for respiratory failure to estimate how much of the higher ICU costs at 1 US site can be attributed to the higher prices paid to ICU personnel, and how much is caused by the US site's use of a higher cost staffing model. We accompanied our TDABC approach with narrative review of the ECMO programs, at Cedars-Sinai (Los Angeles), Hôpital Pitié-Salpêtrière (Paris), and The Alfred Hospital (Melbourne) from 2017 to 2019. Our primary outcome was daily ECMO cost, and we hypothesized that cost differences among the hospitals could be explained by the efficiencies and skill mix of involved clinicians and prices paid for personnel, equipment, and consumables. Our results are presented relative to Los Angeles' total personnel cost per VV ECMO patient day, indexed at 100. Los Angeles' total indexed daily cost of care was 147 (personnel: 100, durables: 5, and disposables: 42). Paris' total cost was 39 (26% of Los Angeles) (personnel: 12, durables: 1, and disposables: 26). Melbourne's total cost was 53 (36% of Los Angeles) (personnel: 32, durables: 2, and disposables: 19) (rounded). The higher personnel prices at Los Angeles explained only 26% of its much higher personnel costs than Paris, and 21% relative to Melbourne. Los Angeles' higher staffing levels accounted for 49% (36%), and its costlier mix of personnel accounted for 12% (10%) of its higher personnel costs relative to Paris (Melbourne). Unadjusted discharge rates for ECMO patients were 46% in Los Angeles (46%), 56% in Paris, and 52% in Melbourne. We found that personnel salaries explained only 30% of the higher personnel costs at 1 Los Angeles hospital. Most of the cost differential was caused by personnel staffing intensity and mix. This study demonstrates how TDABC may be used in ICU administration to quantify the savings that 1 US hospital could achieve by delivering the same quality of care with fewer and less-costly mix of clinicians compared to a French and Australian site. Narrative reviews contextualized how the care models evolved at each site and helped identify potential barriers to change.
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http://dx.doi.org/10.1213/ANE.0000000000006074DOI Listing
June 2022

What is the Current State of Extended Reality Use in Otolaryngology Training? A Scoping Review.

Laryngoscope 2022 May 12. Epub 2022 May 12.

Department of Otolaryngology-Head and Neck Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.

Objective: To map current literature on the educational use of extended reality (XR) in Otolaryngology-Head and Neck Surgery (OHNS) to inform teaching and research.

Study Design: Scoping Review.

Methods: A scoping review was conducted, identifying literature through MEDLINE, Ovid Embase, and Web of Science databases. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. Studies were included if they involved OHNS trainees or medical students who used XR for an educational purpose in OHNS. XR was defined as: fully-immersive virtual reality (VR) using head-mounted displays (HMDs), non-immersive and semi-immersive VR, augmented reality (AR), or mixed reality (MR). Data on device use were extracted, and educational outcomes were analyzed according to Kirkpatrick's evaluation framework.

Results: Of the 1,434 unique abstracts identified, 40 articles were included. All articles reported on VR; none discussed AR or MR. Twenty-nine articles were categorized as semi-immersive, none used occlusive HMDs therefore, none met modern definitions of immersive VR. Most studies (29 of 40) targeted temporal bone surgery. Using the Kirkpatrick four-level evaluation model, all studies were limited to level-1 (learner reaction) or level-2 (knowledge or skill performance).

Conclusions: Current educational applications of XR in OHNS are limited to VR, do not fully immerse participants and do not assess higher-level learning outcomes. The educational OHNS community would benefit from a shared definition for VR technology, assessment of skills transfer (level-3 and higher), and deliberate testing of AR, MR, and procedures beyond temporal bone surgery. Laryngoscope, 2022.
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http://dx.doi.org/10.1002/lary.30174DOI Listing
May 2022

Advancing the assessment of clinical reasoning across the health professions: Definitional and methodologic recommendations.

Perspect Med Educ 2022 03 7;11(2):108-114. Epub 2022 Mar 7.

Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

The importance of clinical reasoning in patient care is well-recognized across all health professions. Validity evidence supporting high quality clinical reasoning assessment is essential to ensure health professional schools are graduating learners competent in this domain. However, through the course of a large scoping review, we encountered inconsistent terminology for clinical reasoning and inconsistent reporting of methodology, reflecting a somewhat fractured body of literature on clinical reasoning assessment. These inconsistencies impeded our ability to synthesize across studies and appropriately compare assessment tools. More specifically, we encountered: 1) a wide array of clinical reasoning-like terms that were rarely defined or informed by a conceptual framework, 2) limited details of assessment methodology, and 3) inconsistent reporting of the steps taken to establish validity evidence for clinical reasoning assessments. Consolidating our experience in conducting this review, we provide recommendations on key definitional and methodologic elements to better support the development, description, study, and reporting of clinical reasoning assessments.
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http://dx.doi.org/10.1007/s40037-022-00701-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8940991PMC
March 2022

Factors affecting perceived credibility of assessment in medical education: A scoping review.

Adv Health Sci Educ Theory Pract 2022 03 27;27(1):229-262. Epub 2021 Sep 27.

Institute of Health Sciences Education, McGill University, 1110 Pine Ave West, Montreal, QC, H3A 1A3, Canada.

Assessment is more educationally effective when learners engage with assessment processes and perceive the feedback received as credible. With the goal of optimizing the educational value of assessment in medical education, we mapped the primary literature to identify factors that may affect a learner's perceptions of the credibility of assessment and assessment-generated feedback (i.e., scores or narrative comments). For this scoping review, search strategies were developed and executed in five databases. Eligible articles were primary research studies with medical learners (i.e., medical students to post-graduate fellows) as the focal population, discussed assessment of individual learners, and reported on perceived credibility in the context of assessment or assessment-generated feedback. We identified 4705 articles published between 2000 and November 16, 2020. Abstracts were screened by two reviewers; disagreements were adjudicated by a third reviewer. Full-text review resulted in 80 articles included in this synthesis. We identified three sets of intertwined factors that affect learners' perceived credibility of assessment and assessment-generated feedback: (i) elements of an assessment process, (ii) learners' level of training, and (iii) context of medical education. Medical learners make judgments regarding the credibility of assessments and assessment-generated feedback, which are influenced by a variety of individual, process, and contextual factors. Judgments of credibility appear to influence what information will or will not be used to improve later performance. For assessment to be educationally valuable, design and use of assessment-generated feedback should consider how learners interpret, use, or discount assessment-generated feedback.
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http://dx.doi.org/10.1007/s10459-021-10071-wDOI Listing
March 2022

Endarkening the Epistemé: Critical Race Theory and Medical Education Scholarship.

Acad Med 2021 11;96(11S):Si-Sv

Y.S. Park is immediate past chair, RIME Program Planning Committee, associate professor, Harvard Medical School, and director of health professions education research, Massachusetts General Hospital, Boston, Massachusetts; ORCID: http://orcid.org/0000-0001-8583-4335.

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http://dx.doi.org/10.1097/ACM.0000000000004373DOI Listing
November 2021

A multicenter randomized clinical trial of pharmacological vitamin B1 administration to critically ill patients who develop hypophosphatemia during enteral nutrition (The THIAMINE 4 HYPOPHOSPHATEMIA trial).

Clin Nutr 2021 08 24;40(8):5047-5052. Epub 2021 Jul 24.

The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia.

Background: Hypophosphatemia may be a useful biomarker to identify thiamine deficiency in critically ill enterally-fed patients. The objective was to determine whether intravenous thiamine affects blood lactate, biochemical and clinical outcomes in this group.

Method: This randomized clinical trial was conducted across 5 Intensive Care Units. Ninety critically ill adult patients with a serum phosphate ≤0.65 mmol/L within 72 h of commencing enteral nutrition were randomized to intravenous thiamine (200 mg every 12 h for up to 14 doses) or usual care (control). The primary outcome was blood lactate over time and data are median [IQR] unless specified.

Results: Baseline variables were well balanced (thiamine: lactate 1.2 [1.0, 1.6] mmol/L, phosphate 0.56 [0.44, 0.64] mmol/L vs. control: lactate 1.0 [0.8, 1.3], phosphate 0.54 [0.44, 0.61]). Patients randomized to the intervention received a median of 11 [7.5, 13.5] doses for a total of 2200 [1500, 2700] mg of thiamine. Blood lactate over the entire 7 days of treatment was similar between groups (mean difference = -0.1 (95 % CI -0.2 to 0.1) mmol/L; P = 0.55). The percentage change from lactate pre-randomization to T = 24 h was not statistically different (thiamine: -32 (-39, -26) vs. control: -24 (-31, -16) percent, P = 0.09). Clinical outcomes were not statistically different (days of vasopressor administration: thiamine 2 [1, 4] vs. control 2 [0, 5.5] days; P = 0.37, and deaths 9 (21 %) vs. 5 (11 %); P = 0.25).

Conclusions: In critically ill enterally-fed patients who developed hypophosphatemia, intravenous thiamine did not cause measurable differences in blood lactate or clinical outcomes.

Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN12619000121167).
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http://dx.doi.org/10.1016/j.clnu.2021.07.024DOI Listing
August 2021

RIME 60 Years: Celebration and Future Horizons.

Acad Med 2021 11;96(11S):S13-S16

Y.S. Park is immediate past chair, RIME Program Planning Committee, associate professor, Harvard Medical School, and director of health professions education research, Massachusetts General Hospital, Boston, Massachusetts; ORCID: http://orcid.org/0000-0001-8583-4335.

This year marks the 60th anniversary (1961-2021) of Research in Medical Education (RIME). Over the past 6 decades, RIME has selected medical education research to be presented each year at the Association of American Medical Colleges Annual Meeting: Learn Serve Lead and published in a supplement of Academic Medicine. In this article, the authors surveyed RIME chairs from the past 20 years to identify ways that RIME has advanced medical education research and to generate ideas for future directions. RIME chairs described advancements in the rigor and impact of RIME research and the timeliness of the topics, often serving as a driver for cutting-edge research. They highlighted RIME's role in promoting qualitative research, introducing new epistemologies, and encouraging networking as a means of career advancement. Going forward, RIME chairs suggested (1) strengthening collaborations with formal advanced MEd and PhD degree programs, (2) creating formal mentorship channels for junior and minority faculty, and (3) promoting research related to knowledge translation.
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http://dx.doi.org/10.1097/ACM.0000000000004296DOI Listing
November 2021

The impact of distance on post-ICU disability.

Aust Crit Care 2022 07 25;35(4):355-361. Epub 2021 Jul 25.

Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; Monash Partners Academic Health Science Centre, Australia. Electronic address:

Background: Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.

Objectives: The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.

Methods: This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received >24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU: <50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p < 0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.

Results: A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living <50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.
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http://dx.doi.org/10.1016/j.aucc.2021.05.013DOI Listing
July 2022

Decontamination effectiveness and the necessity of innovation in a large-scale disaster simulation.

Am J Disaster Med 2021 Winter;16(1):67-73

Associate Professor, Institute of Health Sciences Education and Department of Medicine, McGill University, Montreal, Canada.

Background: Chemical, biological, radiologic, nuclear, and explosive (CBRNE) events threaten the health and integrity of human populations across the globe. Effective decontamination is a central component of CBRNE disaster response.

Objective: This paper provides an objective determination of wet decontamination effectiveness through the use of a liquid-based contaminant proxy and describes the mobilization and adaptation of easily available materials for the needs of decontamination in pediatric victims.

Methods: In this in-situ disaster simulation conducted at a pediatric hospital, decontamination effectiveness was determined through a liquid-based contaminant proxy, and standard burn charts to systematically estimate affected total body surface area (TBSA) in 39 adult simulated patients. Two independent raters evaluated TBSA covered by the contaminant before and after decontamination.

Results: On average, simulated patients had 59 percent (95 percent CI [53, 65]) of their TBSA covered by the simulated contaminant prior to decontamination. Following a wet decontamination protocol, the average reduction in TBSA contamination was 81 percent (95 percent CI [74, 88]). There was high inter-rater reliability for TBSA assessment (intraclass correlation coefficient = 0.83, 95 percent CI [0.68, 0.92]. A modified infant bath was tested during the simulated decontamination of infant mannequins and thereafter integrated to the local protocol.

Conclusion: Wet decontamination can remove more than 80 percent of the initial contaminant found on adult simulated patients. The use of a liquid-based visual tool as a contaminant proxy enables the inexpensive evaluation of decontamination performance in a simulated setting. This paper also describes an innovative, low-cost adaptation of a local decontamination protocol to better meet pediatric needs.
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http://dx.doi.org/10.5055/ajdm.2021.0388DOI Listing
May 2021

"It's a Big Part of Being Good Surgeons": Surgical Trainees' Perceptions of Error Recovery in the Operating Room.

J Surg Educ 2021 Nov-Dec;78(6):2020-2029. Epub 2021 Apr 19.

Institute for Health Sciences Education, McGill University, Montreal, Quebec, Canada; Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada. Electronic address:

Background: The burden of surgical error is high - errors threaten patient safety, lead to increased economic costs to society, and contribute to physician and resident burnout. To date, the majority of work has focused on strategies for reducing the incidence of surgical error, however, total error eradication remains unrealistic. Errors are, to some extent, unavoidable. Adequate preparation for practice should include optimal ways to manage and recover from errors; yet, these skills are rarely taught or assessed.

Objectives: This study aims to explore residents' perceptions and experiences of surgical error recovery. More specifically, we documented participant definitions of error recovery, and explored factors that were perceived to influence error recovery experiences and training in the operating room.

Method: Guided by a qualitative descriptive approach, we conducted semi-structured interviews with residents and fellows in surgical specialties in Canada and the United States. Purposive and snowball sampling were used to recruit residents and fellows in postgraduate year 1 to 5. Interviews were transcribed, analyzed and inductively coded.

Results: A total of 15 residents and fellows participated. When exploring the importance of error recovery for the trainees, competency and safety emerged as main themes, with error recovery being considered an indicator of overall surgical competency. Data concerning factors perceived to influence error recovery training were grouped under 4 major themes: (1) supervision (supervisor-related factors such as attending behaviors and reactions to errors), (2) self (factors such as self-assessed competency), (3) surgical context (factors related to the specific surgery or patient), and (4) situation safeness. Situational safeness was identified as a transversal theme describing factors to be considered when balancing between patient safety and the learning benefits of error recovery training.

Conclusion: Error recovery was considered to be an important skill for safe surgical practice and was considered an important educational target for learners during surgical training. Trainees' opportunities to learn to recover from technical errors in the OR are perceived to be influenced by several factors, leading to variable experiences and inconsistent opportunities to practice error recovery skills. Focusing on factors related to "supervision," "self," "surgery," and "situational safeness" may be an initial framework on which to build initial educational interventions to support the development of error recovery skills to better support safe surgical practice.
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http://dx.doi.org/10.1016/j.jsurg.2021.03.015DOI Listing
March 2022

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

JAMA 2020 10;324(13):1317-1329

School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

Design, Setting, And Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

Main Outcomes And Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

Conclusions And Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

Trial Registration: ClinicalTrials.gov Identifier: NCT02735707.
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http://dx.doi.org/10.1001/jama.2020.17022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489418PMC
October 2020

Learner handover: Perspectives and recommendations from the front-line.

Perspect Med Educ 2020 10;9(5):294-301

Department of General Practice, Université de Liège, Liège, Belgium.

Introduction: Current medical education models increasingly rely on longitudinal assessments to document learner progress over time. This longitudinal focus has re-kindled discussion regarding learner handover-where assessments are shared across supervisors, rotations, and educational phases, to support learner growth and ease transitions. The authors explored the opinions of, experiences with, and recommendations for successful implementation of learner handover among clinical supervisors.

Methods: Clinical supervisors from five postgraduate medical education programs at one institution completed an online questionnaire exploring their views regarding learner handover, specifically: potential benefits, risks, and suggestions for implementation. Survey items included open-ended and numerical responses. The authors used an inductive content analysis approach to analyze the open-ended questionnaire responses, and descriptive and correlational analyses for numerical data.

Results: Seventy-two participants completed the questionnaire. Their perspectives varied widely. Suggested benefits of learner handover included tailored learning, improved assessments, and enhanced patient safety. The main reported risk was the potential for learner handover to bias supervisors' perceptions of learners, thereby affecting the validity of future assessments and influencing the learner's educational opportunities and well-being. Participants' suggestions for implementation focused on who should be involved, when and for whom it should occur, and the content that should be shared.

Discussion: The diverse opinions of, and recommendations for, learner handover highlight the necessity for handover to maximize learning potential while minimizing potential harms. Supervisors' suggestions for handover implementation reveal tensions between assessment-of and for-learning.
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http://dx.doi.org/10.1007/s40037-020-00601-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7550510PMC
October 2020

Sound Practices: An Exploratory Study of Building and Monitoring Multiple-Choice Exams at Canadian Undergraduate Medical Education Programs.

Acad Med 2021 02;96(2):271-277

L. Varpio is professor of medicine and associate director of research, Health Professions Education graduate degree program, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0002-1412-4341.

Purpose: Written examinations such as multiple-choice question (MCQ) exams are a key assessment strategy in health professions education (HPE), frequently used to provide feedback, to determine competency, or for licensure decisions. However, traditional psychometric approaches for monitoring the quality of written exams, defined as items that are discriminant and contribute to increase the overall reliability and validity of the exam scores, usually warrant larger samples than are typically available in HPE contexts. The authors conducted a descriptive exploratory study to document how undergraduate medical education (UME) programs ensure the quality of their written exams, particularly MCQs.

Method: Using a qualitative descriptive methodology, the authors conducted semistructured interviews with 16 key informants from 10 Canadian UME programs in 2018. Interviews were transcribed, anonymized, coded by the primary investigator, and co-coded by a second team member. Data collection and analysis were conducted iteratively. Research team members engaged in analysis across phases, and consensus was reached on the interpretation of findings via group discussion.

Results: Participants focused their answers around MCQ-related practices, reporting using several indicators of quality such as alignment between items and course objectives and psychometric properties (difficulty and discrimination). The authors clustered findings around 5 main themes: processes for creating MCQ exams, processes for building quality MCQ exams, processes for monitoring the quality of MCQ exams, motivation to build quality MCQ exams, and suggestions for improving processes.

Conclusions: Participants reported engaging multiple strategies to ensure the quality of MCQ exams. Assessment quality considerations were integrated throughout the development and validation phases, reflecting recent work regarding validity as a social imperative.
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http://dx.doi.org/10.1097/ACM.0000000000003659DOI Listing
February 2021

Surgical Errors Happen, but Are Learners Trained to Recover from Them? A Survey of North American Surgical Residents and Fellows.

J Surg Educ 2020 Nov - Dec;77(6):1552-1561. Epub 2020 Jul 18.

Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada; Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada. Electronic address:

Background: Surgical training necessitates graded supervision and supported independence in order to reach competence. In developing surgical skills, trainees can, and will, make mistakes. A key skill required for independent practice is the ability to recover from an error or unexpected complication. Error recovery includes recognizing and managing a technical error in order to ensure patient safety and may be underrepresented in current educational approaches.

Objective: The purpose of this study is to explore residents' experiences and perceptions of error recovery training in surgical procedures.

Method: An online survey was sent to surgical program directors in the United States and Canada using the Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada distribution lists. Participating programs distributed the survey to their residents and fellows. The survey was composed of Likert-scale items, yes/no questions as well as open-ended questions focused on perceptions, experiences, and factors that influence to error recovery training in the operating room.

Results: A total of 206 surveys were completed. Overall, 99% (n = 203) agreed or strongly agreed that error recovery is an important competency for future practice. This was reflected in free-text response: "Errors can be minimized but they are inevitable, so certainly believe a surgical curriculum that addresses error recovery is of paramount importance." While 83% (n = 170) feel confident recovering from minor errors, only 34% (n = 68) feel confident that they could recover from major errors that are likely to have serious consequences on patient safety. Overall, residents do not consider that they have adequate training in error recovery, with only 37% (n = 72) felt they were adequately trained to recover from major errors. It was also mentioned "The quality of learning regarding error recovery depends entirely on the attending."

Conclusions: Opportunities to learn to recover from technical errors in the operating room are valued by surgical trainees, but they perceive their training to be both inadequate and variable. This contributes to a lack of confidence in error recovery skills throughout their surgical training. There is a need to explore how best to integrate error recovery into more formal surgical curricula in order to better support learners and, ultimately, contribute to increased surgical safety.
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http://dx.doi.org/10.1016/j.jsurg.2020.05.031DOI Listing
June 2021

Does Educational Handover Influence Subsequent Assessment?

Acad Med 2021 01;96(1):118-125

M. Young is associate professor, Institute of Health Sciences Education and Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; ORCID: http://orcid.org/0000-0002-2036-2119.

Purpose: Educational handover (i.e., providing information about learners' past performance) is controversial. Proponents argue handover could help tailor learning opportunities. Opponents fear it could bias subsequent assessments and lead to self-fulfilling prophecies. This study examined whether raters provided with reports describing learners' minor weaknesses would generate different assessment scores or narrative comments than those who did not receive such reports.

Method: In this 2018 mixed-methods, randomized, controlled, experimental study, clinical supervisors from 5 postgraduate (residency) programs were randomized into 3 groups receiving no educational handover (control), educational handover describing weaknesses in medical expertise, and educational handover describing weaknesses in communication. All participants watched the same videos of 2 simulated resident-patient encounters and assessed performance using a shortened mini-clinical evaluation exercise form. The authors compared mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups using analyses of variance. They examined potential moderating effects of supervisor experience, gender, and mindsets (fixed vs growth).

Results: Seventy-two supervisors participated. There was no effect of handover report on assessment scores (F(2, 69) = 0.31, P = .74) or percentage of negative comments (F(2, 60) = 0.33, P = .72). Participants who received a report indicating weaknesses in communication generated a higher percentage of comments on communication than the control group (63% vs 50%, P = .03). Participants who received a report indicating weaknesses in medical expertise generated a similar percentage of comments on expertise compared to the controls (46% vs 47%, P = .98).

Conclusions: This study provides initial empirical data about the effects of educational handover and suggests it can-in some circumstances-lead to more targeted feedback without influencing scores. Further studies are required to examine the influence of reports for a variety of performance levels, areas of weakness, and learners.
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January 2021

Postpositivism in Health Professions Education Scholarship.

Acad Med 2020 05;95(5):695-699

M.E. Young is associate professor, Institute of Health Sciences Education and Department of Medicine, McGill University, Montreal, Quebec, Canada; ORCID: http://orcid.org/0000-0002-2036-2119. A. Ryan is associate professor and director of assessment, Department of Medical Education, Melbourne Medical School, University of Melbourne, Melbourne, Australia; ORCID: https://orcid.org/0000-0002-0480-5522.

An understanding of the diversity of perspectives within the research paradigms of health professions education (HPE) is essential for rigorous research design and more purposeful engagement with the contributions of others. In this article, the authors explicitly discuss the underlying assumptions, notions of good scholarship, and shortcomings of the postpositivism research paradigm. While postpositivism is likely one of the more familiar paradigms within HPE research, it is rarely formally or explicitly described. Drawing on key literature and contemporary examples, the authors describe the ontology, epistemology, methodologies, axiology, signs of rigor, and common critiques of postpositivism. A case study provides the focus for a practical illustration of how a postpositivist approach to education research could be applied. Suggestions for further reading are provided for those who are keen to delve deeper into the history and key tenants of the postpositivist stance.
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http://dx.doi.org/10.1097/ACM.0000000000003089DOI Listing
May 2020

Mapping clinical reasoning literature across the health professions: a scoping review.

BMC Med Educ 2020 Apr 7;20(1):107. Epub 2020 Apr 7.

Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

Background: Clinical reasoning is at the core of health professionals' practice. A mapping of what constitutes clinical reasoning could support the teaching, development, and assessment of clinical reasoning across the health professions.

Methods: We conducted a scoping study to map the literature on clinical reasoning across health professions literature in the context of a larger Best Evidence Medical Education (BEME) review on clinical reasoning assessment. Seven databases were searched using subheadings and terms relating to clinical reasoning, assessment, and Health Professions. Data analysis focused on a comprehensive analysis of bibliometric characteristics and the use of varied terminology to refer to clinical reasoning.

Results: Literature identified: 625 papers spanning 47 years (1968-2014), in 155 journals, from 544 first authors, across eighteen Health Professions. Thirty-seven percent of papers used the term clinical reasoning; and 110 other terms referring to the concept of clinical reasoning were identified. Consensus on the categorization of terms was reached for 65 terms across six different categories: reasoning skills, reasoning performance, reasoning process, outcome of reasoning, context of reasoning, and purpose/goal of reasoning. Categories of terminology used differed across Health Professions and publication types.

Discussion: Many diverse terms were present and were used differently across literature contexts. These terms likely reflect different operationalisations, or conceptualizations, of clinical reasoning as well as the complex, multi-dimensional nature of this concept. We advise authors to make the intended meaning of 'clinical reasoning' and associated terms in their work explicit in order to facilitate teaching, assessment, and research communication.
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http://dx.doi.org/10.1186/s12909-020-02012-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140328PMC
April 2020

Being Edgy in Health Professions Education: Concluding the Philosophy of Science Series.

Acad Med 2020 07;95(7):995-998

A. MacLeod is professor and director of education research in continuing professional development, Faculty of Medicine, Dalhousie University, Halifax, Canada. R.H. Ellaway is professor, Department of Community Health Sciences, and director, Office of Health and Medical Education Scholarship, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. E. Paradis is assistant professor, status-only, University of Toronto, and a scientist, Wilson Centre, Toronto, Ontario, Canada. Y.S. Park is associate professor and associate head, Department of Medical Education and Director of Research, Office of Educational Affairs, University of Illinois College of Medicine, Chicago, Illinois. M. Young is associate professor, Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada. L. Varpio is professor, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

The philosophy of science is concerned with what science is, its conceptual framing and underlying logic, and its ability to generate meaningful and useful knowledge. To that end, concepts such as ontology (what exists and in what way), epistemology (the knowledge we use or generate), and axiology (the value of things) are important if somewhat neglected topics in health professions education scholarship. In an attempt to address this gap, Academic Medicine has published a series of Invited Commentaries on topics in the philosophy of science germane to health professions educational science. This Invited Commentary concludes the Philosophy of Science series by providing a summary of the key concepts that were elucidated over the course of the series, highlighting the intent of the series and the principles of ontology, epistemology, axiology, and methodology. The authors conclude the series with a discussion of the benefits and challenges of cross-paradigmatic research.
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July 2020

Nudging clinical supervisors to provide better in-training assessment reports.

Perspect Med Educ 2020 02;9(1):66-70

Department of Medicine and Institute of Health Sciences Education; Faculty of Medicine, McGill University, Montreal, QC, Canada.

Introduction: In-training assessment reports (ITARs) summarize assessment during a clinical placement to inform decision-making and provide formal feedback to learners. Faculty development is an effective but resource-intensive means of improving the quality of completed ITARs. We examined whether the quality of completed ITARs could be improved by 'nudges' from the format of ITAR forms.

Methods: Our first intervention consisted of placing the section for narrative comments at the beginning of the form, and using prompts for recommendations (Do more, Keep doing, Do less, Stop doing). In a second intervention, we provided a hyperlink to a detailed assessment rubric and shortened the checklist section. We analyzed a sample of 360 de-identified completed ITARs from six disciplines across the three academic years where the different versions of the ITAR were used. Two raters independently scored the ITARs using the Completed Clinical Evaluation Report Rating (CCERR) scale. We tested for differences between versions of the ITAR forms using a one-way ANOVA for the total CCERR score, and MANOVA for the nine CCERR item scores.

Results: Changes to the form structure (nudges) improved the quality of information generated as measured by the CCERR instrument, from a total score of 18.0/45 (SD 2.6) to 18.9/45 (SD 3.1) and 18.8/45 (SD 2.6), p = 0.04. Specifically, comments were more balanced, more detailed, and more actionable compared with the original ITAR.

Discussion: Nudge interventions, which are inexpensive and feasible, should be included in multipronged approaches to improve the quality of assessment reports.
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http://dx.doi.org/10.1007/s40037-019-00554-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012977PMC
February 2020

The Spectrum of Inductive and Deductive Research Approaches Using Quantitative and Qualitative Data.

Acad Med 2020 07;95(7):1122

associate professor, Institute of Health Sciences Education and Department of Medicine, McGill University professor, Department of Medicine, Uniformed Services University of the Health Sciences professor, Department of Medicine, Uniformed Services University of the Health Sciences assistant professor and Canada Research Chair, Collaborative Healthcare Practice, The Wilson Centre, University Health Network, Leslie Dan Faculty of Pharmacy and Department of Sociology, University of Toronto.

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http://dx.doi.org/10.1097/ACM.0000000000003101DOI Listing
July 2020

The utility of failure: a taxonomy for research and scholarship.

Authors:
Meredith Young

Perspect Med Educ 2019 12;8(6):365-371

Department of Medicine and Institute for Health Sciences Education, McGill University, Montreal, QC, Canada.

Introduction: Health professions education (HPE) research and scholarship utilizes a range of methodologies, traditions, and disciplines. Many conducting scholarship in HPE may not have had the opportunity to consider the value of a well-designed but failed scholarly project, benefitted from role-modelling of the value of failure, nor have engaged with the common nature of failure in research and scholarship.

Methods: Drawing on key concepts from philosophy of science, this piece describes the necessity and benefit of failure in research and scholarship, presents a taxonomy of failure relevant to HPE research, and applies this taxonomy to works published in the Perspectives on Medical Education failures/surprises series.

Results: I propose three forms of failure relevant to HPE scholarship: innovation-driven, discovery-oriented, and serendipitous failure. Innovation-driven failure was the most commonly represented type of failure in the failures/surprises section, and discovery-oriented the least common.

Conclusions: Considering failure in research and scholarship, four conclusions are drawn. First, failure is integral to research and scholarship-it is how theories are refined, discoveries are made, and innovations are developed. Second, we must purposefully engage with the opportunities that failure provide-understanding why a particular well-designed project failed is an opportunity for further insight. Third, we must engage publicly with failure in order to better communicate and role model the complexities of executing scholarship or innovating in HPE. Fourth, in order to make failure truly an opportunity for growth, we must, as a community, humanize and normalize failure as part of a productive scholarly approach.
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http://dx.doi.org/10.1007/s40037-019-00551-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904373PMC
December 2019

Scoping reviews in health professions education: challenges, considerations and lessons learned about epistemology and methodology.

Adv Health Sci Educ Theory Pract 2020 10 25;25(4):989-1002. Epub 2019 Nov 25.

Institute of Health Sciences Education, McGill University, Montreal, QC, Canada.

Scoping reviews are increasingly used in health professions education to synthesize research and scholarship, and to report on the depth and breadth of the literature on a given topic. In this Perspective, we argue that the philosophical stance scholars adopt during the execution of a scoping review, including the meaning they attribute to fundamental concepts such as knowledge and evidence, influences how they gather, analyze, and interpret information obtained from a heterogeneous body of literature. We highlight the principles informing scoping reviews and outline how epistemology-the aspect of philosophy that "deals with questions involving the nature of knowledge, the justification of beliefs, and rationality"-should guide methodological considerations, toward the aim of ensuring the production of a high-quality review with defensible and appropriate conclusions. To contextualize our claims, we illustrate some of the methodological challenges we have personally encountered while executing a scoping review on clinical reasoning and reflect on how these challenges could have been reconciled through a broader understanding of the methodology's philosophical foundation. We conclude with a description of lessons we have learned that might usefully inform other scholars who are considering undertaking a scoping review in their own domains of inquiry.
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http://dx.doi.org/10.1007/s10459-019-09932-2DOI Listing
October 2020
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