#KeyLIMEpodcast 119: #Hellomynameis… Definitions in #Meded

This week the Key Literature in Medical Education podcast is a live recording from the International Conference on Medical Education. We welcome a guest host, Eric Warm, an amazing Clinician Educator who is ahead of the curve on programmatic assessment, quality improvement and many other areas in medical education.

While the methods leave a lot to be desired, the paper is a starting point to help you to articulate what a Clinician Educator is.

**Warning** Conflict-of-interest**

A companion paper that you might want to read on defining a Clinician Educator can be found here. I find this graphic from the paper particularly helpful.

Fig 4.png
From Sherbino, Frank and Snell. Academic Medicine, 2014 89 (5): 783-789


Before you commit to digging into the topic, check out the abstract below, and then check out the podcast here.

– Jonathan


KeyLIME Session 119 – Article under review:

New KeyLIME Podcast Episode Image

Varpio L, Gruppen L, Hu W, O’Brien B, Ten Cate O, Humphrey-Murto S, Irby DM, van der Vleuten C, Hamstra SJ, Durning SJ. Working Definitions of the Roles and an Organizational Structure in Health Professions Education Scholarship: Initiating an International Conversation. Academic Medicine. 2016 Aug 30. [Epub ahead of print]

Reviewer: Jonathan Sherbino


One of the consistently frustrating phenomena in health professions education is the inconsistent application of a lexicon.  I know.  You’ve heard this rant from me before.  But give me my 5 minutes on a soapbox.  (As a complete aside, and I’m unsure why I have this chip missing in my brain, I have a strong dislike of the adjective “educational.”  I much prefer the attributive [adjectival] use of the noun “education”, as in education scholarship, NOT educational scholarship.  So, I’m really happy to see this form in the title!  Ok, sorry for that. Back to the paper.)

Imprecise definitions relevant to health professions education (HPE) scholarship, result in decreased profile, support, and promotion for scholars.  This paper attempts to achieve an ‘international’ (Canada, Australia, New Zealand, United States and Netherlands) consensus of three distinct archetypal roles in HPE.


“The authors define and offer illustrative examples of three professional roles in HPES (clinician educator, HPES research scientist, and HPES administrative leader) and an organizational structure that can support HPES participation (HPES unit).”

Type of Paper

Consensus paper informed by interviews.

Key Points on Methods

The international author group does not provide any detailed insight into the methods that inform their work.  While it is not informed by an organizing theory, nor does it use a systematic approach to gather qualitative data to answer their research question, it is informed by a series of interviews with directors of medical education research and innovation units in Canada and HPES leaders in Australia and New Zealand.  The definitions were refined in an iterative fashion by the authors based on the interviews.

The work is not informed by existing literature on roles and definitions in HPE.

Key Outcomes

There is overlap (think Venn diagram) among all of the roles.

“A clinician educator:

  1. Is trained as a clinician in a health profession, AND
  2. Engages (or has previously engaged) in clinical activities, AND
  3. Actively engages in health professions educational activities, AND
  4. Consistently engages in and disseminates health-professions related educational scholarship.”

“An HPES research scientist:

  1. Holds a graduate-level degree (usually at the PhD level, but occasionally at the master’s level) in an academic discipline (e.g., education, psychology, anatomy, or engineering), AND
  2. Is formally required to engage in health-professions-related educational scholarship”

“An HPES administrative leader focuses primarily on educational leadership activities, such as being the academic lead of a substantial component of a health professions education training program (e.g., deans, assistant deans, department chairs). HPES administrative leaders can come from any discipline or professional background, and they are expected to promote or lead clinician educators and/or HPES research scientists to pursue the scholarship of learning and teaching related to HPES. HPES administrative leaders must also engage in and disseminate education-related scholarship.”

“An [HPE scholarship unit] is an organizational structure within which a group of people, often those working in the roles described above, is substantively engaged in HPES.

  1. The unit must stand as a recognizable, coherent, organizational identity within the institution,” AND 2. The unit must be identified as engaging in health professions education- related scholarship. This scholarship may be conducted at the undergraduate, graduate, and/ or continuing education levels. The unit may also house programs that focus on teaching, service provision, professional development program delivery, etc., but these other activities alone are not sufficient for being identified as an HPESU without the scholarship contributions.”

Key Conclusions

The authors conclude…

“With these working definitions, scholars and administrative leaders can examine HPES roles and organizational structures across and between national contexts to decide how lessons learned in other contexts can be applied to their local contexts.”

Spare Keys – other take home points for clinician educator

A great example of education scientists and clinician educators collaborating on a shared goal to promote HPE.

Shout out

Thanks to Linda Snell, who couldn’t join us for this podcast, but graciously allowed me to steal her paper🙂

Listen to the podcast here

Resilient #MedEd #Leaders: Bending to Adapt

(From the E-i-C:  This is the third installment on emerging philosophy and tactics for leaders in education.  You can find Part 1 here and Part 2 here.  Stay tuned for the ebook version of this whole series Spring 2017.  For advance registration to access a copy of the book Resilient #MedEd Leaders email us at ice@royalcollege.ca


 By Felix Ankel  and Nico Pronk, PhD

“The best is the enemy of the good.”


You are a #meded leader charged with integrating health professions education within a health system. Operational changes within the system are evolving in an exponential fashion. Educational imperatives are also evolving but are perceived to be lagging behind. How can you align these forces? How can you bend the current system to adapt and accelerate change?

There is a debate about what elements of resilience are related to the capacity of the individual to handle stress, a.k.a. the gene code (see Daniel Cabrera’s excellent posts here and here), and what elements are related to the capacity of the system to handle stress, a.k.a. the zip code.

This is the third of four posts in the #meded leadership series that focus on developing resilient educational programs able to handle system stress (the zip code). The four topics include:

  1. Identifying clear values
  2. Maximizing the density of connections
  3. Maximizing the ability to bend and adapt (discussed in this post)
  4. Incorporating systematic reflective practice

Challenges to bending and adapting

Educational programs stick to the status quo for many reasons: Program directors and faculty are comfortable with it, external accreditation and compliance standards are interpreted in a conservative fashion, and hierarchical organizational structures favor perfectionism and the “illusion of central position” rather than rapid prototyping and rapid failure for learning.

Clinicians have minimal tolerance for error or competing points of view unless backed by compelling data. In academia, committees promote faculty based on the number of peer-reviewed publications and grants, which are surrogates reputation. These forces can produce an “illusion of central position,” where the interpretation of external data is constrained by an inward-facing, deficit-based lens that stifles program innovation and creativity.

This “culture of central position” results in #meded programs being produced and “perfected” without input from diverse stakeholders. Such a production model often leads to small technical improvements, but it does not address the adaptive transformation needed to train the clinicians of the future to work in the environment of the future.

Shifting cognitive perspective

#meded programs and leaders of the future will benefit by developing competencies to remain adaptive and relevant in rapidly evolving health care environments.

One such technique is the ABCD of shifting perspective created by Albert Ellis. The activating event is one that causes stress (e.g., a resident being pulled from an endocrinology service). The belief is the immediate thoughts or assumptions about the event (that the residency does not value endocrinology training). The consequence is the emotion or behavior that is developed (anger and hostility toward the residency director). The dispute involves challenging the initial belief by coming up with a list of alternative beliefs (the resident is pulled from service for reasons unrelated to endocrinology).

#meded leaders that can embed cognitive perspective–shifting competencies in their team will help educational programs bend, adapt, and maintain resilience in a rapidly changing world.

Nico Pronk’s first-person case study in an industry different from #meded, which follows, discusses how maximizing the ability to bend can serve as the foundation for building a resilient system.

Case study: maximizing the ability to bend and adapt

Human capital refers to an organization’s people and their health, expertise, and motivation to function and perform. The ability of an organization’s culture to “bend” according to the evolving and emerging needs of its environment has a profound impact upon the performance of the organization and its people.

Over the course of the past 10 years, I studied the journey of a medium-sized manufacturing company located in the Upper Midwest. In 2003, the company’s Minneapolis location numbered about 500 employees, among whom more than 30 languages were spoken. The company’s performance was floundering and a new CEO was brought in. The CEO decided to focus on the company’s workers as its main asset and lead an intentional effort to create a culture of health and safety that reflected clear values, ethical leadership, support for worker well-being, and organizational performance. In the process, the company built a culture that reflects an organizational capacity to bend and adapt and provides a context in which people (the human capital) can thrive.

Health and well-being

The manufacturer built a platform for worker health and well-being that was intentionally designed to go beyond individual programs and address needs holistically. Support from leaders was enhanced by access to on-site medical clinic, pharmacy, and health-coaching services, sponsored retirement savings programs and financial counseling, profit sharing for retirement, “work-life pursuit” time, company match for volunteering, promoting from within, and tuition reimbursement, among other benefits.


The company created a leadership and development track to support managers and supervisors in optimizing all aspects of employee and organizational health and well-being. All executive, mid-level, and front-line leaders participate in this ongoing program, which includes training in social and emotional intelligence, leadership effectiveness and authenticity, goal setting and coaching, and intrinsic needs assessments.


Year-round communications that bring recognition to the services and experiences of the employees and transparency around the company’s performance in the market optimized employees’ energy and motivation to bring their best selves to work every day. The notion of pursuing a “human-centered” culture meant not only paying attention to physical health needs that allow employees to be at work but also to issues that matter most to employees and their families. Through the introduction of “stay” interviews, coaching, and mentoring programs, the voice of the employee is loud and clear.

Why do these changes matter?

Having the ability to bend and adapt as a company is important for health and well-being, education and expertise, and motivation—and vice versa. In fact, a focus on human capital is equally responsible for building the ability to bend and adapt as any other factor. Hence, maximizing the capacity to bend is a leading indicator of a culture of health and safety.

Companies recognized for their cultures of health and safety tend to outperform the market, as measured by the average Standard & Poor’s 500, by as much as 5% to 17%. Over the 10-year journey the medium-sized company described above took to build such a positive culture, it experienced a turnover rate reduction from 15% in 2003 to less than 1% in 2012. (The industry average is 13%). Employee surveys indicated that 93% of the company’s employees give their best effort each day and 91% put in extra effort as needed. Such results reinforce that the benefits of this long-term view include building resilience among people as well as in the organization as a whole.

When building resilient educational programs, consider the following:

  1. Beware of the limitations of perfectionism. Embrace rapid failure, rapid prototyping. Champion human-centered design.
  2. Beware of the illusion of central positioning. Design your programs from many points of view. Embrace criticism as energy for creativity and innovation.
  3. Maximize your cognitive bending practice. Consider embedding the ABCD approach of shifting perspective into your program for maximal resilience.
  4. Recognize the value of investment in human capital, especially health, well-being, and education of your people.



Kahneman Daniel, Tversky, Amos.  On the Reality of Cognitive Illusions. Psychol. Rev. 1996; 103(3):582-591

Kegan Robert, Lahey, Lisa.  An Everyone Culture, Becoming a Deliberately Developmental Organization. Harvard Business Review Press 2016

Lipsenthal, Lee. Finding Balance in a Medical Life. Finding Balance, Inc. 2007

Pronk NP. LifeWorks@TURCK: A best practice case study on workplace well-being program design. ACSM’s Health & Fitness Journal. 2015;19(3):43-48.

A #meded Ronin: Do You Teach Outside The Lines?

By Damian Roland

Dr. Donald Freeman is one of the few remaining general clinicians left at The Maidhup General Hospital. In a time of increasing super-specialisation, “The Don” still leads clinics that include patients with problems ranging from headache to hiccoughs. The Don was one of the first physicians employed by the hospital when it opened 35 years ago and he has performed many management roles. However, his blunt, honest style started to grate with the executive committee and he now concentrates solely on clinical practice.

 He is famous at the local university amongst the medical students. They speak affectionately of being “Don’d,” which describes his special way of being able to gently chastise lack of knowledge without being derogatory or belittling. His lectures are consistently highly rated, yet the university struggles with his lack of engagement with objective setting, diary planning and examination invigilating. Where possible he still uses chalk and a board and has somehow managed to avoid being recorded for any of the university’s lecture repositories. He shuns both social media and the hugely expensive bespoke learning platform that was designed specifically for tutors to engage with students. He has been voted clinical teacher of the year for 3 out of the past 5 years.

 taiso_-_ronin_fending_off_arrows_cph-3g08655The ronin were samurai warriors in feudal Japan who became outcasts due to their own indiscretions or the death of their masters. The fact that they were samurai, and the association with a major Hollywood title of the same name has given them a slightly mythical and potentially revered quality. The term actually means ‘wave man’ and is associated with being a drifter. Many ronin unable to access honourable work turned to crime or eventually became vagrants.

I prefer the use of ronin as a ‘rogue’ warrior – someone with immense skill and flair, but who operates outside of normal convention. My suspicion is that there are ‘Dons’ in every hospital. These ‘educational’ ronin do not tow traditional faculty lines yet they have a huge impact on the education of students and doctors. Educational ronin can be extremely challenging for directors of education or faculty leads. They create a tension between role modeling professional values (it is usually very apparent to the students that ‘the Don’ doesn’t play ball with the medical school) and allowing the creative freedom in pedagogy that all institutions who deliver curriculum need.

I have previously talked on #meded #donoharm  bemoaning the fact that we don’t really have a list of education interventions or methodologies to avoid. This makes it easy for educators who get positive feedback from their students (regardless of their overall outcomes) to remain unchallenged about their practices. But are educational ronin such a bad thing? In fact is it useful to have rogues pushing the boundaries and potentially raising others faculties games? Allowing dyscompetent physicians through the system has been has been cited as breaking our commitment to patients, but educational ronin are not necessarily dyscompetent educators.

In what ways may you be considered an educational ronin?  And, are you going to do anything about it?

Thanks to @ketaminh who I think first coined the term educational ronin.

#KeyLIMEpodcast 118: How to Select Trainees in #Meded

The Key Literature in Medical Education podcast tackles selection methods this week.  From the help of our Aussi friends at onthwardsMarie-Louis Stokes and Anthony Llewellyn, we try to determine whether graphology (i.e. the study of handwriting to differentiate candidates… seriously, this used to be a thing) or behavioural interviewing (i.e. having the candidate perform a representative task relevant to the discipline) or another method can help you weed out the outstanding candidate from your towering stack of applications.

As a McMaster University faculty, I need to give a shout out to the MMI (Multiple Mini Interview) technique that did not get discussed in the podcast.  If you’re curious more details here.

For more details on selection techniques, check out the abstract below.  For a richer debate on how this classic paper from psychology informs medical education, check out the podcast here.

– Jonathan


KeyLIME Session 118 – Article under review:

New KeyLIME Podcast Episode Image

Schmidt F, Hunter, JE. The Validity and Utility of Selection Methods in Personnel Psychology: Practical and Theoretical Implications of 85 Years of Research Findings. 1998. Psychological Bulletin; 124(2):262-274.

Reviewer: Anthony Llewellyn(@drallewellyn)


This is a classic and often cited study from the psychology literature.

Implicit to the role of many clinician educators is selection.  We often spend significant amounts of time devoted to the process of selecting students into medical school and doctors for trainee and higher level jobs.  We generally draw our colleagues, support staff and other professionals into the process.  The time-related costs of all this activity are often significant.

Selection into medical schools and training posts is competitive in a number of countries.  Yet often it seems that a “standard approach” to job selection for trainee positions has been in place for some time, i.e. submission of a paper based job application, if too many applications there is generally a paper-based culling process, followed by an interview with a panel and some form of reference check.

Many lead authors in the medical eudcation space such as Fiona Patterson suggest that there may be better approaches such as: assessment centres; multiple mini interviews; and situational judgement tests.

The Schmidt and Hunter paper, whilst somewhat dated now is one most often cited as a source paper in both medical education articles looking at the selection question as well as in many mainstream human resource and organizational texts.


In this paper the authors look at the performance of 19 various types of selection tools for personnel recruitment by summarizing 20 plus years of prior work.

Type of Paper

Systematic review; Meta-analysis; Commentary.

Key Points on Methods

The authors summarize the development of research into personell selection techniques which commenced in the 1900s.  It was soon evident that some techniques were more valid than others.  Research from post World War II revealed that the findings for the validity of selection techniques were not only valid in certain work categories, when combined in meta-analyses, with very little to no variability.  But that equally very little to no variability was found when studies combined results across work categories.

The authors compile meta-analytic findings of 19 personell selection techniques which have been trialled in combination.

The General Mental Ability (GMA) test is identified as the gold standards selection test versus which all other tests have been trialed in combination with this test.

The authors present findings for the GMA in combination with other tests for both job performance post selection as well as performance in a job training program post selection.

The statistical techniques are somewhat valid and would be deemed acceptable for their time period.  The authors do not give any information as to how they sourced their studies for the review.

Key Outcomes

The authors note that GMA is noted in the research to be the most valid predictor of future performance when hiring someone who has not performed the job before.

Whilst not an area of comment for this article the reviewers agree that we could consider the GMA as equivalent to the level of mental ability one requires to successfully gain entry into medical school and thereafter we are likely to be dealing with professionals with quite high levels of GMA (or equivalent).

In combination with GMA the following techniques were found to be most powerful in improving selection for job performance:

  • Work Sample Tests (24% increase in validity)
  • Integrity Tests (27% increase in validity)
  • Structured Interviews (24% increase in validity)

In combination with GMA the following techniques were found to be most powerful in improving selection for performance in job training programs:

  • Integrity Tests (20% increase in validity)
  • Conscientiousness Tests (16% increase in validity)

A number of techniques were found to have no or little increase in validity, including:

  • Job experience
  • Biographical Data
  • Assessment Centres
  • Points method for evaluating training and experience
  • Years of education
  • Interests
  • Age
  • Graphology

Techniques that were somewhere in the middle included:

  • Job knowledge tests
  • Job tryouts
  • Peer ratings
  • Behaviorally consistent method of assessing training and experience
  • Reference checks

Key Conclusions

The authors conclude that the cumulative findings show that research knowledge now available make it possible for employers to substantially increase the productivity, output and learning ability of their workforces by using procedures that work well and by avoiding those that do not.

The authors suggest that a combination of assessment of GMA + integrity or GMA + structured interview are the best approach for personnel selection dependent upon the circumstances of selection.

The authors recognize that their study is limited to those studies looking at two techniques in combination and that many selection processes involve a greater number of tools.  They further suggest that some techniques are likely to combine aspects of different selection techniques, for e.g. a structured interview may at the same time assess GMA, as well as training and experience using behavioural interviewing techniques.

The authors also suggest that many employers are currently using suboptimal selection techniques.

Spare Keys – other take home points for clinician educator

This article is worth knowing about as it is often cited by Human Resource and Organizational Psychology aspects when looking at the best approach to selection.

You may wish to keep a copy of the tables handy if you are reviewing your selection processes.

It is worth considering that some of the selection techniques which are indicated to significantly improve validity are often not often utilized in selection processes in medicine, even where this may actually make rational sense and might be easily applied.

For e.g. selection processes for procedural training programs could incorporate a basic work sample test, such as demonstrating a procedure on a training mannequin.

Possibly even more worrying is the use of techniques which are seen to be far less valid, for e.g. assigning points for training and experience from an application or resume which is often seen in some medical training selection processes.

It is possible that with increased competition trainees may choose to challenge the validity of selection processes based on evidence (or lack of).

Challenges in adopting new and improved processes for selection into medical school and/or medical positions include:

  • Time and resources required to redesign the process
  • Convincing those with a stake in the existing process that it is worth changing


Listen to the podcast here

The Impostor Syndrome and Medical Education

By Anthony Llewellyn

Recently I hosted an inaugural Medical Education event in my local area.  One of the key, repeated claims from many of our speakers was of Impostor Syndrome.  It became quite a theme throughout the conference.  The typical argument went something along the line of “well really I don’t consider myself to be a medical educationalist first and foremost so I was a bit surprised to be asked to give a talk on the medical education topic of …”

Given that the participant feedback indicated a high quality of presentation and content from our speakers, the claim of Impostor Syndrome seemed to be justified.

The Impostor Syndrome was first hypothesized by a pair of  clinical psychologists Pauline Clance and Suzanne Imes in 1978 to describe a phenomenon they had observed in their practices amongst high-achieving individuals (predominantly women).  These individuals struggled to accept their accomplishments, despite contrary external evidence and constantly feared being placed in an expert role as they might be discovered to be a fraud.

fraud.jpgBy the way Impostor Syndrome is not a mental disorder, it didn’t make it into the latest DSM5.  But there are still reasons to take this issue seriously.


Is it surprising that Clinician Educators feel like imposters or is it a broad phenomenon within medicine?  In a 2008 article in the Journal of General Internal Medicine of 48 participating internal medicine residents 44% were reported in a survey to exhibit signs of “impostorisim.”  It is probably not surprising that doctors might feel fraudulent, particularly at times of transition in our medical careers. For example, when transitioning from an undergraduate to a postgraduate or when asked to talk at a medical education conference.

I’ve recently transitioned back into clinical practice and I am feeling the IS myself.  I felt that my first day in outpatient practice was possibly my worst work day in a long time.  I was particularly troubled by the amount of time it took me to document my patient encounters.  To deal with this I found it reassuring to discuss my experience and cases within a peer review group and get my documentation confidentially checked by a peer.  I soon discovered that my experience was quite normal.

One worrying consequence of IS is its potential impact on patient care. A colleague and I noticed an inverse relationship between the seniority of the trainee and the amount of times that they would review a patient with the consultant when on-call.  We had some data on the numbers of patient presentations and admission to compare  with the actual frequency of calls.  This would often get to a point of comedic-tragedic proportions where I can recall having meetings with trainees around wanting to write detailed policies about when trainees should call the consultant.  When I talked to the trainees about why it was they called more as a senior trainee versus a junior trainee their responses indicated that junior trainees felt they were not experienced enough and didn’t know enough to call the consultant (were worried about embarrassing themselves), whereas senior trainees highly valued the opportunity to discuss with a consultant because they felt it was more of a peer relationship.

I’ve talked to other colleagues from other disciplines about this observation and they have seen it as well.  By definition its not true Impostor Syndrome, but its something quite close. Doctors close in experience/capability and seniority to other doctors are less anxious about revealing a weakness than those further apart.

I am starting a simple experiment to counter this problem.  Each morning after my on-call I send the trainee a quick email thanking them for being on-call and giving them feedback on the presentations from the night before.  If I hadn’t been called I remind them that I was on-call and still hoped the night went well for them.  The results are still out.

What about you?  Have you encountered Impostor Syndrome in your work?  Have you developed any methods of addressing the seniority gap in patient handover?

Image courtesy of The Blue Diamond Gallery

Live stream the International Conference on Residency Education (ICRE)

No offical post today, as we are at the International Conference on Residency Education (ICRE), taking place from Thursday, September 29 – Saturday October 1.

This year’s event takes place in Niagara Falls, ON and the theme is Advancing Quality: Aligning Residency Education and Patient Care.

We didn’t want you to miss you if you couldn’t make it, so please click below to enjoy the live feed to some of the conference’s most scintillating events! Continue reading “Live stream the International Conference on Residency Education (ICRE)”