In Aristotle’s scheme, phronesis is classified as one of several ‘intellectual virtues’ (Eikeland, 2008). Aristotle (1975) distinguished phronesis from the intellectual virtues of episteme and techne. In Aristotle’s conception (Flyvberg, 2001) episteme is characterised as scientific, universal, invariable, context‐independent knowledge. Techne is characterised as context‐dependent, pragmatic, variable, craft knowledge, oriented toward practical rationality and governed by a conscious goal. Phronesis, on the other hand, is an intellectual virtue that implies ethics. It involves deliberation based on values, concerned with practical judgement and informed by reflection. It is pragmatic, variable, context‐dependent, and oriented toward action.

This investigation began with a shared sense that something of fundamental importance—of moral significance—was missing in the vision of what it means to be a professional, and in the ensuing educational aims in professional schools. The project was framed around the question: “If we take phronesis seriously as an organising framework for professional knowledge, what are the implications for professional education and practice?” The purpose of this paper is to discuss some of the emergent insights generated from this investigation and the implications for health professional education.

1. Aristotle (1975). The Nicomachean ethics. Boston: D. Reidel.

2. Eikeland, O. (2008). The ways of Aristotle: Aristotlean phronesis, Aristotlean philosophy of dialogue, and action research. Bern, Switzerland: Peter Lang.

Research on medical expertise has traditionally focused on understanding routine problem solving patterns in order to train for efficient approaches to common problems. Currently, however, expertise research is grappling with the question of how experts adapt to novel challenges, and how we can better train for flexibility and innovation in the face of uncertainty. The present study seeks to further the understanding in this area, by exploring the nature of the challenges experts encounter and the processes by which they assess and respond to challenges.

2. Methods

This study followed an ethnographic approach involving intraoperative observations and postoperative interviews with expert surgeons. Six faculty surgeons were selected through purposive sampling. Two to three surgical cases were observed per surgeon. A template analysis was implemented and NVivo qualitative data analysis software was used to apply the thematic coding structure and to support the interpretive analysis.

3. Results

Two key aspects of surgical challenges were identified: the nature of surgical challenges, and the actions performed by experts to derive information about the challenge. Intraoperative challenges manifested in three different types: judgment challenges, technical challenges and situational challenges. When surgeons found themselves ‘inside’ a challenge, they would seek and interpret particular patterns of cues to assess the nature of the challenge. Cue‐seeking activities seemed to be specific to challenge types.

4. Discussion

The definitional distinction between different types of challenges provided by this study is new in the surgical literature, and may constitute the first part of a language for defining a taxonomy of adaptations exerted by surgical experts when facing complex situations. From an educational perspective, this language might help surgical faculty render explicit their tacit adaptive strategies for training purposes.

Methods: This was a pilot prospective cohort study. Participants were divided into two groups by arthroscopy experience: experts (n = 8) and novices (n = 10). Each participant performed six repetitions of four procedures. Performance measures were provided by the VR simulator and included time to completion, distance covered, and roughness. Scores for each parameter were summed for every session and performance curves were constructed by plotting the group mean and standard deviation.

Results: Novices improved consistently in all parameters measured without reaching a plateau by the sixth session, while experts demonstrated a steeper initial improvement but reached a plateau as early as the second session. Experts outperformed novices in terms of time and distance covered, but by the last session, novices approached expert levels for all parameters measured. The VR simulator also demonstrated construct validity by successfully distinguishing between expert and novice groups (Mann‐Whitney U Test p < 0.01).

Conclusions: This pilot study provided preliminary evidence to inform the integration of the insight ARTHRO VR® simulator into a training curriculum by establishing factors like the amount of training necessary to achieve an expert level of skill. While the virtual reality simulator improves the performance of novices in simulated arthroscopy, its ability to teach arthroscopic skills that are transferrable to a real operating room environment requires further study.

OBJECTIVES: This study aims to capture spatially complex translational flaps using 3‐D videography and implement the footage into an e‐learning module. The second aim is to assess the role of 3‐D video as a medium to support skill acquisition in novices using e‐learning modules.

HYPOTHESIS: The influence of 3‐D learning modules as training tools will correlate positively with VSA and thus, skill acquisition and performance compared to a 2‐D video module of the same lesson.

RESULTS: No significant difference was observed between the mean score of the two video treatment groups. This is supplemented with a trend where students prefer 3‐D treatments as learning tools and exhibit interest in learning additional, more complex surgical procedures in 3‐D.

CONCLUSIONS: Despite a wealth of literature that suggests that 3‐D correlates directly to enhanced skill acquisition, this study did not recover significant results contributing to increased performance. This topic will continue to be explored using more complex procedures which capitalize on depth perception.

Methods: A literature review was performed and preliminary hierarchical decompositions were created. Three expert surgeons were observed for 8 to 10 typical cases; they were asked to verbalize the steps and their cognitive choices. The preliminary MCMD was reviewed by the surgeons to ensure face validity of the tool.

Results: MCMDs were created for knee arthroscopies and ligament reconstructions. With the task decomposition and the qualitative data derived from the interviews, we identified teachable components of the procedures for using simulations.

Conclusions: MCMDs provide accurate representations of the motor and cognitive aspects of arthroscopy and the critical aspects of surgeries. Future research will integrate these decompositions into a simulation‐based orthopaedic training curriculum at our University. Different metrics are currently being tested and used along with the MCMD.

1. Mabrey JD, Reinig KD, Cannon WD. Virtual reality in orthopaedics: Is it a reality? Clin Orthop Relat Res. 2010 Oct;468(10):2586‐91.

2. Cristancho SM, Hodgson AJ, Pachev G, Nagy A, Panton N, Qayumi K. Assessing cognitive & motor performance in minimally invasive surgery (MIS) for training & tool design. Stud Health Technol Inform. 2006;119:108‐13.

While medical reasoning research has the potential to influence clinical and teaching practice, to date, its impact has been limited by a nearly exclusive focus on diagnosis. To begin setting a new agenda for research in this field, the purpose of this study was to develop a taxonomy of reasoning tasks that a physician engages in during a clinical encounter.

Methods

A purposeful sample of 46 international researchers in the field participated in a two‐phase, modified online Delphi in order to develop consensus on a list of reasoning tasks.

Summary of Results

Thirty participants responded (65%); 66% were physicians and 38% had doctoral degrees. As a result of the Delphi, 24 reasoning tasks were identified and organized into four broad categories: 1) Problem identification and agenda setting, 2) Diagnostic tasks, 3) Management tasks, and 4) Self‐assessment tasks. Examples of each include: Identify active issues; identify modifiable risk factors; determine the impact of co‐morbid illness on management; identify knowledge gaps.

Conclusions

The identification this taxonomy represents a first step in broadening the research agenda to embrace this list of tasks and their interactions. Results can be used to inspire new research questions such as “how do different levels of performers deal with task switching and multi‐tasking during an encounter”?

METHODS: Using an evidence‐based approach, a microsurgical skills curriculum was devised using an established model. Beginning on inanimate objects and culminating in live vascular anastomosis on an anesthetized rat, three residents developed microsurgical skills including use of the microscope, handling of delicate tissue, hemostasis and microsurgical suturing. Performance assessment is underway, through blinded expert review of video‐recordings of the tasks using validated outcome measures. Upon completion of the program, participants will be evaluated on a live operative task (Carotid Endaterectomy) to determine skill transfer to the OR. Their performance will be compared with three control subjects.

RESULTS: All participants have successfully completed the training program and are now completing the operative task, with interim analysis underway. We hypothesize that a statistically significant improvement in skills will be observed within each resident over the course of the training program and when compared to controls on the operative task.

Method: The ethics education program for psychiatry residents at the University of Western Ontario consists of an introductory course and a quarterly seminar. The residents participate in a pre‐test and post‐test for the introductory course, and submit a report after the presentation for the quarterly seminar. The pre‐test and post‐test scores of the introductory course and the score of the quarterly seminar were quantitatively evaluated. The seminar report was qualitatively analyzed.

Results: The test scores of the introductory course improved from the pre‐test to post‐test (p=0.00). Gender difference was not statistically significant regarding the introductory course pre‐test scores (p=1.00), score improvement between the pre‐test and post‐test (p=0.95), and seminar report scores (p=0.14). The findings from the seminar reports are as follows: Most residents applied principlism. Few residents had inaccurate knowledge and skills in ethical theories. Residents expressed various attitudes regarding patient autonomy, beneficence and justice, demonstrated uncertainty tolerance to varying degrees, valued the doctor‐patient/family relationship, were rather critical toward peers, and considered psychiatry as unique among medical specialties in terms of ethical issues involved in practice.

Conclusions: The introductory course may contribute to the acquisition of ethics knowledge. Most residents have correct knowledge of ethical theories and skills to apply them. Residents expressed diverse attitudes concerning ethical issues.

This study sought to fill the gap in knowledge regarding what specific clinical skills could be strengthened through rigorous training in Narrative Medicine (NM), focusing on the areas of communication, collaboration, professionalism, patient‐centeredness, and self‐awareness.

Method

Two qualitative methods (open ended survey questions/focus group) were used to collect process and outcome assessment data from twelve students enrolled in an intensive one‐month NM elective. An iterative thematic analysis of both datasets was carried out by each author. Data triangulation was achieved.

Results

Response rate for the weekly survey was 91% and focus group participation was 50%. Five major findings about the role and potential of NM in medical education emerged: students develop and improve specific communication skills; enhance empathy and affiliation with others; are provided with desired and rare opportunities to reflect on themselves and the practice of medicine; report that the pedagogical approach used in NM training is critical to the dividends; and indicate that current perceptions of NM stymie the potential influence and uptake of this field.

Conclusions

Results from two modes of data collection strongly support the use of NM as a means of developing communication, affiliation, and reflective capability. The authors contend that these skills are integral to medical practice and intrinsic to several core competencies mandated by the Accreditation Council for Graduate Medical Education (ACGME) and the Royal College of Physicians and Surgeons of Canada (RCPSC‐CANMEDs). The findings suggest that the process and dividends of this field can influence the culture of medical training.

The authors conducted a systematic curriculum audit at a large research‐based Canadian university that sought to determine undergraduate students’ pre‐clinical exposure to geriatric content. A database was created following a detailed inventory of all existing clinical scenarios used in testable coursework and learning materials during the 2008‐09 academic year. From each clinical scenario information was extracted regarding patient age, gender, and presenting illness, as well as existing medical, social, cognitive, and functional issues, to determine typical patient profiles presented to students prior to clerkship.

920 clinical scenarios were identified. Mean patient age was 37.7 (SD 21.9). The most commonly presented age group was 26‐45 (277 cases or 30.1% of total). Only 130 cases (14.1%) featured patients 65 or older. Patients ≥75 featured in 54 cases (5.87%) and of those only 11 (1.2%) were ≥85 years. Medical, cognitive, and functional issues were consistently underreported across all age groups; common geriatric syndromes such as delirium, dementia, and depression were reported in 20 cases (1.74%).

Older patients are critically underrepresented in case‐based pre‐clinical curriculum at this site. Immediate research is needed to assess whether underrepresentation of older patients is common in undergraduate medical pedagogy and, if so, what steps should be taken to increase geriatric content.

There is little opportunity for medical students and residents to receive feedback on specific geriatric skills as medical trainees are frequently unsupervised when assessing elderly patients. Patients and their caregivers are currently an untapped source for clinical content feedback. The purpose of this study was to determine if patient‐caregiver pairs could accurately complete a post‐assessment evaluation of trainees’ clinical performance and thus serve as a resource to enhance their assessment skills.

Method.

A Comprehensive Geriatric Assessment Guide (CGAG) was developed consisting of 36 yes/no/don’t remember questions prompting the patient‐caregiver to indicate what topics were actually discussed during their assessment. In 2010, two raters independently listened to audio‐recordings of 10 assessments administered by medical trainees and scored the CGAG to determine inter‐rater reliability. Next, 32 patient‐caregiver pairs completed a CGAG after assessment by a medical trainee with their results compared to a gold‐standard CGAG of the encounter.

Results.

Inter‐rater reliability scores for the CGAG were near perfect (94.8% agreement). Thirty out of 36 CGAG questions had patient‐caregiver and gold‐standard agreement of over 80%, while 6 out of 36 questions had low agreement.

Conclusions.

Patients and their caregivers are able to recall sufficient assessment detail to provide constructive feedback to medical trainees on their assessment skills. The six questions with low agreement will be reworded to improve clarity on future versions of the CGAG. Use of CGAG during medical education may help students improve assessment performance and allow educators to track progress in geriatric competencies.

Through analysis of interviews and focus groups with interdisciplinary doctoral students and supervisors, the role of different members of the research team was identified as an important component of successful interdisciplinary research. Participants discussed the process of compiling a team of supervisors, co‐supervisors, supervisory committee members and examiners who were understanding and supportive of working in an interdisciplinary way. Conceptions of effective interdisciplinary teams included developing a language to bridge disciplinary differences, coming to a common understanding of expectations for the student's work, defining roles of team members, and shaping team composition to include the necessary areas of experience and knowledge.

Although academic centres rely on assessments from postgraduate trainees for data regarding the effectiveness of their faculty as teachers, we know little about how residents conceptualize their role within the clinical teaching assessment (CTA) process.

Methods

Using a constructivist grounded theory approach, five focus group interviews were conducted with 19 residents from an internal medicine residency program. Constant comparative analysis of emergent themes was conducted.

Results

Residents reported that they struggled throughout the academic year to meet their CTA obligations and several shortcutting strategies were described to reduce their burden. Rather than conceptualize their assessments as being a conduit for both formative and summative feedback, residents perceived CTAs as being useful for the surveillance of clinical supervisors who were perceived to be at the extremes of the teaching spectrum. Residents indicated that they devoted the most effort, including the crafting of written comments, towards the CTAs of these faculty ‘outliers.’ Trainees desired greater transparency in the CTA process and were skeptical regarding the anonymity and perceived validity of their faculty appraisals.

Conclusions

Multiple individual and system‐based factors conspire to influence postgraduate medical trainees’ motivation for generating high‐quality appraisals of clinical teaching.

Methods: In a constructivist grounded theory study, we interviewed 22 early‐career academic physicians about experiences they perceived as influential in their learning, deriving a model of clinical learning in which feedback emerged as one of a number of important learning cues. To better understand how feedback becomes (or fails to become) influential, we used the theoretical framework of regulatory focus to re‐examine and re‐code all instances where the experience of receiving and responding to feedback was described.

Results: Feedback could be influential or non‐influential, regardless of its sign (positive or negative). In circumstances where the individual’s regulatory focus was readily determined, such as choosing a career (promotion) or preparing for a high‐stakes examination (prevention), the apparent influence of feedback was consistent with the prediction of regulatory focus theory. However, we encountered many challenges in applying regulatory focus theory to real scenarios, including the frequent presence of a mixed regulatory focus, the potential for regulatory focus to change over time, and the competing influence of other factors, such as feedback’s credibility.

Conclusions: Regulatory focus theory offers a useful, if limited, construct for understanding learners’ responses to feedback in the clinical setting. The insights and predictions it offers must be considered in light of the motivational complexity of clinical learning tasks and of other factors which influence feedback’s impact.

1. Kluger AN, Van Dijk D. Feedback, the various tasks of the doctor, and the feedforward alternative. Med Educ 2010;44:1166‐1174.