The diagnosis and management of patients requires professional know-how or medical craft knowledge. To explain how this knowledge is acquired, this research asked 'How do medical experts pass on their craft?' Other questions arose through successive data collections and progressive focusing on what medical experts did well in their work and teaching. The programme comprised: pilot interviews with three expert physicians; a case study in a hospital medical unit; and paired consultant/SHO interviews. Participant observation, interviews, and expert-novice comparisons explored clinical work, teaching, and learning in apprenticeship. Data analysis of participants' responses and ward round discussions allowed identified categories to cluster within three inter-related constructs instrumental to the acquisition of medical knowledge: gaining experience in the experiential process of clinical practice (1); and the products of experience which manifest as experts' clinical expertise (2) and teaching/learning expertise (3). These constructs can be located within a model of apprenticeship based on Spady's (1973) analysis of authority in effective teaching containing two frames of reference: the social, 'traditional-legal'; and the individual, 'expert-charismatic'. The medical apprenticeship is associated with similar perspectives: the 'traditional-experiential' represents the professional process of learning through patient care with its infrastructure of clinical methods in presentation, discourse, and commentary; and the 'expert-charismatic' represents clinical and teaching expertise coupled with vocational enthusiasm. Experienced experts synthesised two repertoires of knowledge and skills derived from the craft knowledge of medicine and pedagogy, respectively. Both crafts are required for effective clinical education. While apprenticeship accommodates a range of teaching/learning experiences, in postgraduate education experts pass on knowledge through the deliberate engagement of junior doctors in diagnosis and management. The skills involved in this process were largely unrecognised by most senior and junior doctors and were not perceived as 'clinical teaching' although learning was structured through service-based work.

Appropriate coding is a daunting task for new physicians just entering the world of medical practice. This is mostly due to the ever-changing standards for reimbursement, and the constant demand on provider time from an ever-growing number of patients to serve from a primary care perspective. It has been shown that family physicians lose up to 10- 20 percent of reimbursement each year because of incorrect coding. Physicians are the ones responsible for appropriately coding their work and documentation so that the clinic can be fairly reimbursed. In the East Tennessee State University Family Physicians of Bristol residency program, there is a strong tendency for most physicians to under-code the majority of office visits to a 99213, despite the fact that their documentation of these visits reflects coding at much higher levels. The goal of this project is to provide more intensive education to resident physicians on the requirements for coding, and thus change behaviors that led to continued under-coding. Researchers in this project utilized aggregate data collected in the course of the usual practice of business to show the present state of coding behaviors as broken down by resident, and then re-assessed these numbers after the presentation of more intensive education regarding appropriate coding. Education was provided in a variety of formats, including 4 short lectures at didactic sessions over the course of several months, as well as handouts for residents to keep with them at nurses’ stations containing guidelines for coding. Data analysis is currently underway. It is expected that the implementation of the educational program will have led to a statistically significant increase in appropriate coding within the clinic. This result has important implications regarding education to improve appropriate coding and reimbursement, particularly for small clinics operating in rural regions that are at the highest risk of harm from under-reimbursement due to inaccurate coding.

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Current and aspiring medical school students are inundated by curriculum resources. To optimize the curriculum resources that are offered in medical education, the present work examines both institutionally and commercially developed resources from the lens of various stakeholders through three separate, yet related, studies. The first study, a scoping review, synthesizes and recognizes gaps in scholarship regarding obstacles that underrepresented, pre-medical students encounter in applying to medical school, specifically focusing on the impact of access to commercial test preparation resources. A review of existing literature regarding this population's medical school admission difficulties yielded a majority of non-empirical, deficit-focused articles that repeated previous findings. The second study describes a pedagogical analysis of medical education commercial resources, to identify their alignment with evidence-based design and facilitate future improvement. The analysis found that nearly half of the investigated resources failed to mention guidance by a specific theory or theoretical movement; yet all resources mentioned similar functions, instructional strategies, and features. Lastly, this dissertation reports a mixed-methods study that examines undergraduate medical students' perceptions and use of formal and informal resources, to optimize the design of formal resources and integrate informal resources. Qualitative and quantitative data analyses revealed that students have more positive perceptions and frequent use of informal curriculum resources, which is largely explained by greater confidence in conducting their related educational activities.

Nursing students struggle to acquire and maintain clinical psychomotor skills. Hiring agencies bear the cost of retraining graduate nurses inept with skills learned early in their nursing curriculum. Improperly performed clinical skills pose a risk to patient safety, resulting in pain and suffering for the patient. This empirical study aimed to determine if video-enhanced debriefing (VED) improved initial skill validation scores, skill feedback, satisfaction with learning, and reduced skill decay among first-semester, pre-licensure BSN students performing female indwelling urinary catheterization (IUC) in a simulated clinical setting compared to no debriefing. Participants received standard instruction, then video-recorded their IUC skill. Participants randomized into the VED group individually participated in an advocacy/inquiry debriefing with the principal investigator while viewing their performance video. Both groups completed a summative IUC skill validation per standard course instruction and submitted their skill performance ratings. All participants completed a survey including their perceived IUC knowledge, amount of skill practice, learning satisfaction with VED, and an evaluation of their skill performance feedback. All participants re-recorded their IUC skill and received performances ratings with the same instruments again ten weeks after the initial skill validation. The analysis revealed that VED did not improve nursing skills, knowledge, practice, or perceptions of the learning experience compared to the video-only group. Nursing students in the VED condition did rate their skill performance feedback higher than those in the video-only group. Students improved performance in both conditions, showing that learning via video is an effective teaching strategy to enhance student's satisfaction with learning, to engage in repetitive practice with feedback, and to improve learning.

In regions of the world that experience a deficit of surgical care, educational initiatives can foster the development of a skilled surgical workforce. Implicit in training these health workers is the mandate to retain them in the country in order build capacity. Eyal’s framework presents ways in which locally relevant training can improve retention and outlines the ethical and pragmatic concerns of such initiatives. In 2006, Guyana established it’s first surgical training program, an example of locally relevant training. The University of Guyana Diploma of Surgery (UGDS) program was selected for this case study research. Consistent data collection, supported by a systemic procedure to analyze that data, is paramount to increase the effectiveness of the UGDS program. The purposes of this dissertation research were two-fold. Firstly, it sought to understand how the UGDS program influences retention and the ways in which the UGDS members contribute to capacity building and the program’s sustainability. Secondly, this program evaluation provides a useful context to inform Eyal’s framework. 8 graduates, 2 trainees, 4 faculty members and 2 persons identified as policy makers were interviewed. Interviews were conducted face to face, and then transcribed. Surveys were administered to graduates and trainees and reflective journals were coded and analyzed. Overall, the data mapped fairly well onto Eyal’s framework. The results of the study suggest that the benefits and concerns Eyal outlines would be better represented along a continuum rather than being classified as either advantageous or disadvantageous with respect to retention. While Eyal’s claims generalize across settings, he should acknowledge this limitation and consider the important role that context plays. Overall, the results suggest that the UGDS program has positively influenced retention and capacity building. Key recommendations were made to the UGDS program that aim to improve retention and capacity building. As regions continue to face challenges associated with providing adequate surgical care, fostering retention and capacity building is recommended so that a sustainable surgical workforce can meet surgical needs. / Thesis / Master of Health Sciences (MSc)

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Background: Distributed Medical Education sites are satellites of large academic medical schools with faculty who are community-based physicians. These medical teachers need faculty development and there is little data about how this can best be delivered. This study asked the question: How can medical teaching expertise be developed and sustained at a Distributed Medical Education Campus? Using constructivist grounded theory methodology, a total of 16 semi-structured interviews were conducted with faculty members at two DME site campuses in Southern Ontario, and two faculty development events, one at each site, were observed. Findings_ The communitWhat are the perceptions of faculty at a Distributed Medical Education site regarding effective and acceptable faculty development activities for improving their skills as medical educators? y in which a DME campus medical school is implanted is transformed through a process of interaction between learners, medical teachers, and the community itself, which results in the production of expert community teachers. Community based physicians can develop teaching expertise and require faculty development to maintain interest and skill. They can access high quality, relevant faculty development within their own practice groups, a model referred to as a Community of Practice. These communities can be virtual or in-person and need several elements to be successful, including facilitation and mentorship. Conclusion: Teaching experts can develop in a DME site when there is accessible, relevant faculty development, such as in a Community of Practice. More research is needed to determine the best way to reward community teachers, most of whom are part time faculty in private practice. / Thesis / Master of Health Sciences (MSc) / Recently, satellite campuses of medical schools have been established in smaller cities, called Distributed Medical Education (DME) sites. There, the teaching faculty is composed of non-academic, community-based physicians. These faculty members need training to learn how to teach, or Faculty Development. This study asked the question: How can medical teaching expertise be developed and sustained at a Distributed Medical Education Campus? Sixteen interviews were conducted with teaching physicians, and two faculty development events were observed at two DME site campuses in Southern Ontario. The findings of this study revealed that the community is transformed through a process of interaction between learners, medical teachers, and the community itself, resulting in the production of expert community teachers. These teachers can access high quality faculty development within their own practice groups, a model referred to as a Community of Practice.