Exploring the influence of context on feedback at medical school: a video-ethnography study

Systematic review of feedback literacy instruments for health professions students

Successfully managing and utilizing feedback is a critical skill for self-improvement. Properly identifying feedback literacy level is crucial to facilitate teachers and learners especially in clinical learning to plan for better learning experience. The present review aimed to gather and examine the existing definitions and metrics used to assess feedback literacy (or parts of its concepts) for health professions education. A systematic search was conducted on six databases, together with a manual search in January 2023. Quality of the included studies were appraised using the COSMIN Checklist. Information on the psychometric properties and clinical utility of the accepted instruments were extracted. A total 2226 records of studies were identified, and 11 articles included in the final analysis extracting 13 instruments. These instruments can be administered easily, and most are readily accessible. However, 'appreciating feedback' was overrepresented compared to the other three features of feedback literacy and none of the instruments had sufficient quality across all COSMIN validity rating sections. Further research studies should focus on developing and refining feedback literacy instruments that can be adapted to many contexts within health professions education. Future research should apply a rigorous methodology to produce a valid and reliable student feedback literacy instrument.

Feedback practices in undergraduate clinical teaching in Sri Lanka - a qualitative study

BACKGROUND

Feedback is integral to medical education, enabling students to improve their knowledge, skills, and attitudes. Feedback practices may vary according to prevalent cultural and contextual factors. This study aimed to explore how feedback is conceptualized and practised in the clinical education of medical students in Sri Lanka.

METHODS

The study was conducted in three medical schools and affiliated hospitals that represent the cultural diversity of Sri Lanka. Purposive sampling was utilized to recruit clinical teachers and students who would provide rich information for the study. The study had three components: an observation study, interviews with clinical teachers and focus group discussions with clinical students. During the observation study, video recording was used as a data collection tool to observe feedback in real-life clinical teaching/learning settings. A constructivist grounded theory approach was adapted for analysis to explore current practices and perceptions inductively.

RESULTS

Feedback was conceptualised as spontaneous unidirectional provision of information for the improvement of students. It was often provided in public settings and in student groups. Error correction was the primary focus of feedback, but both teachers and students desired a balanced approach with reinforcement and reflection. Although the direct approach to corrective feedback was found beneficial for student learning, participants agreed that harsh feedback was to be avoided. The hierarchical culture and lack of programmed feedback in the curricula influenced feedback practices, suggesting the need for modification.

CONCLUSIONS

This study highlighted feedback practices in the local context, emphasizing the need to address the hierarchical gap in clinical settings, balance reinforcement and correction, and promote dialogue and reflection in the feedback processes. The findings will help clinical teachers from both the global south as well as the global north to recognize cultural and contextual differences in providing feedback.

Designing feedback processes in the workplace-based learning of undergraduate health professions education: a scoping review

BACKGROUND

Feedback processes are crucial for learning, guiding improvement, and enhancing performance. In workplace-based learning settings, diverse teaching and assessment activities are advocated to be designed and implemented, generating feedback that students use, with proper guidance, to close the gap between current and desired performance levels. Since productive feedback processes rely on observed information regarding a student's performance, it is imperative to establish structured feedback activities within undergraduate workplace-based learning settings. However, these settings are characterized by their unpredictable nature, which can either promote learning or present challenges in offering structured learning opportunities for students. This scoping review maps literature on how feedback processes are organised in undergraduate clinical workplace-based learning settings, providing insight into the design and use of feedback.

METHODS

A scoping review was conducted. Studies were identified from seven databases and ten relevant journals in medical education. The screening process was performed independently in duplicate with the support of the StArt program. Data were organized in a data chart and analyzed using thematic analysis. The feedback loop with a sociocultural perspective was used as a theoretical framework.

RESULTS

The search yielded 4,877 papers, and 61 were included in the review. Two themes were identified in the qualitative analysis: (1) The organization of the feedback processes in workplace-based learning settings, and (2) Sociocultural factors influencing the organization of feedback processes. The literature describes multiple teaching and assessment activities that generate feedback information. Most papers described experiences and perceptions of diverse teaching and assessment feedback activities. Few studies described how feedback processes improve performance. Sociocultural factors such as establishing a feedback culture, enabling stable and trustworthy relationships, and enhancing student feedback agency are crucial for productive feedback processes.

CONCLUSIONS

This review identified concrete ideas regarding how feedback could be organized within the clinical workplace to promote feedback processes. The feedback encounter should be organized to allow follow-up of the feedback, i.e., working on required learning and performance goals at the next occasion. The educational programs should design feedback processes by appropriately planning subsequent tasks and activities. More insight is needed in designing a full-loop feedback process, in which specific attention is needed in effective feedforward practices.

Undergraduate Learners' Receptiveness to Feedback in Medical Schools: A Scoping Review

Feedback from educators to learners is considered an important element of effective learning in medical school. While early studies were focused on the processes of providing feedback, recent work has showed that factors related to how learners receive feedback seems to be equally important. Considering that the literature on this topic is new in medical education, and studies are diverse and methodologically variable, we sought to conduct a scoping review to map the articles on receptiveness to feedback, to provide an overview of its related factors, to identify the types of research conducted in this area, and to document knowledge gaps in the existing literature. Using the Joanna Briggs Institute scoping review methodology, we searched four databases (CINAHL, Ovid, PubMed, and Web of Science) and screened 9120 abstracts, resulting in 98 articles for our final analysis. In this sample, 80% of studies on the feedback receiver were published in the last 10 years, and there is a vast variation in the studies' methodologies. The main factors that affect medical students' receptiveness to feedback are students' characteristics, feedback content, educators' credibility, and the learning environment. Feedback literacy is a very recent and rarely used term in medical education; therefore, an important area for further investigation. Lastly, we identified some gaps in the literature that might guide future research, such as studying receptiveness to feedback based on academic seniority and feedback literacy's long-term impacts on learning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01858-0.

Developing residents' feedback literacy in emergency medicine: Lessons from design-based research

Objectives

Residents in emergency medicine have reported dissatisfaction with feedback. One strategy to improve feedback is to enhance learners' feedback literacy-i.e., capabilities as seekers, processors, and users of performance information. To do this, however, the context in which feedback occurs needs to be understood. We investigated how residents typically engage with feedback in an emergency department, along with the potential opportunities to improve feedback engagement in this context. We used this information to develop a program to improve learners' feedback literacy in context and traced the reported translation to practice.

Methods

We conducted a year-long design-based research study informed by agentic feedback principles. Over five cycles in 2019, we interviewed residents and iteratively developed a feedback literacy program. Sixty-six residents participated and data collected included qualitative evaluation surveys (n = 55), educator-written reflections (n = 5), and semistructured interviews with residents (n = 21). Qualitative data were analyzed using framework analysis.

Results

When adopting an agentic stance, residents reported changes to the frequency and tenor of their feedback conversations, rendering the interactions more helpful. Despite reporting overall shifts in their conceptions of feedback, they needed to adjust their feedback engagement depending on changing contextual factors such as workload. These microsocial adjustments suggest their feedback literacy develops through an interdependent process of individual intention for feedback engagement-informed by an agentic stance-and dynamic adjustment in response to the environment.

Conclusions

Resident feedback literacy is profoundly contextualized, so developing feedback literacy in emergency contexts is more nuanced than previously reported. While feedback literacy can be supported through targeted education, our findings raise questions for understanding how emergency medicine environments afford and constrain learner feedback engagement. Our findings also challenge the extent to which this contextual feedback know-how can be "developed" purposefully outside of the everyday work.

'Every Human Interaction Requires a Bit of Give and Take': Medical Students' Approaches to Pursuing Feedback in the Clinical Setting

PhenomenonStudents, alongside teachers, play a key role in feedback. Student behavior in feedback processes may impact feedback outcomes. Student feedback behavior includes recognizing, seeking, evaluating, and utilizing feedback. Student feedback behavior is influenced by numerous student attributes and environmental factors. ApproachWe aimed to explore influences on medical student feedback behavior during clinical attachments. We adopted a subjective inductive qualitative approach. We conducted 7 focus groups with 46 medical students undertaking pediatric hospital-based attachments. We based our discussion framework on existing characterizations of student feedback behavior and the educational alliance model with its focus on the relationship between learners and teachers, and the active role played by both. During initial data analysis, we identified that our results exhibited aspects of Bandura's model of Triadic Reciprocal Causation within Social Cognitive Theory. In line with our subjective inductive approach, we adopted Triadic Reciprocal Causation at this point for further analysis and interpretation. This allowed us to conceptualize the emerging interactions between influences on feedback behavior. Findings We identified three key determinants of student feedback behavior: Environmental influences, Student attributes and Relationships between teachers and students. Environmental influences encompassed factors external to the student, including Teacher attributes and behaviors and The clinical learning context. Through the lens of Triadic Reciprocal Causation, the interrelationships between the determinants of feedback behavior gave rise to five key themes: Interactions between student feedback behavior and environmental influences of the clinical learning context, Interactions between student feedback behavior and environmental influences of teacher attributes and behaviors, Interactions between student attributes and student feedback behavior, Interactions between student attributes and environmental influences of teacher attributes and behaviors, and Relationships and the determinants of student feedback behavior. Insights: We apply the Triadic Reciprocal Causation model of Social Cognitive Theory to understand the influences on student feedback behavior and the interactions between them. We extend the model by situating relationships between students and teachers as a central factor. Future interventions to facilitate students' role in feedback will need to address student attributes, environmental factors, and student-teacher relationships, appreciating the codependent nature of these influences.

The VOTIS, part 2: Using a video-reflexive assessment activity to foster dispositional learning in interprofessional education

Effective interprofessional collaborative practice (IPCP) requires a new way of working characterized by distributed leadership skills, shared decision-making, and the adoption of uniprofessional and interprofessional identities. Health professional educators are tasked with preparing clinicians for IPCP through interprofessional education (IPE). Numerous IPE teaching interventions have been developed, ranging in length from hours to semesters, designed to introduce students to interprofessional ways of working - usually evaluated in terms of student satisfaction, perceptions of other disciplines and conceptual knowledge. However, working interprofessionally also requires integrating dispositional knowledge into one's emerging interprofessional habits and values. In this paper, we describe a learning activity, inspired by a new video-reflexive methodology, designed to foster dispositional learning of interprofessional skills using a video-based assessment tool: the Video Observation Tool for Interprofessional Skills (VOTIS). Based on focus group and interview data, we suggest the activity's usefulness in fostering conceptual, procedural and dispositional knowledge, as well as reflexive feedback literacy. Overall, our qualitative evaluation of the VOTIS suggests the merits of drawing on video-reflexive methodology and pedagogical theory to re-imagine IPE as a dynamic process, requiring the development of interprofessional skills that must be appropriated into students' emerging (inter)professional identities.

The interactional communication of feedback in clinical education: A focused ethnographic study in a hierarchical and collectivist culture

Background

The definition of feedback in clinical education has shifted from information delivery to student-teacher dialogue. However, based on Hofstede's theory, countries with large power distance or a robust social hierarchy and collectivistic cultural dimensions can reduce the feedback dialogue to a minimum. Indonesia is classified in this group, with some Asian, African, Mediterranean, and Latin American countries. This study explores the interactional communication of feedback during clinical education in a hierarchical and collectivistic context.

Methods

The focused ethnographic approach was applied to the clinical rotation program in an Indonesian teaching hospital. Data sources included observations of feedback episodes during workplace-based assessments followed by interviews with clinical supervisors and students. The data were compiled within 16 weeks of observation in 7 groups of clinical departments, consisting of 28 field notes, audiotaped interviews including nine focus group discussions of students (N = 42), and seven in-depth interviews with clinical supervisors. Data were analyzed through transcription, coding, categorization, and thematic analysis using the symbolic interactionist perspective.

Results

We identified four themes representing actual interactional communication and its 'meaning' or interpretation. The interactional communication in feedback is described in the first and second themes, such as 1) Students play the subordinate roles in a feedback dialogue; 2) The feedback content is focused on explanation and students' limitations. The third and fourth themes represent the clinical supervisors' and students' interpretation of their feedback experience, such as 3) Clinical supervisors' perspectives are mostly on dissatisfaction and teaching authority; 4) Students' acceptance of reality and negative affection.

Conclusions

This study shows that the social gap between students and clinical supervisors in Indonesia, and other countries in the same cultural classification, potentially causes communication barriers in the feedback dialogue. The adaptation of 'feedback as a dialogue' requires further effort and research to develop communication strategies in feedback that consider the national culture and context.

'The Obstacle is the Way': Methodological Challenges and Opportunities for Video-Reflexive Ethnography During COVID-19

The COVID-19 pandemic greatly impacted research. In this article, we explore the opportunities and challenges presented by the pandemic to a group of researchers using video-reflexive ethnography (VRE) - a methodology used to understand practices, grounded in: exnovation, collaboration, reflexivity, and care. To understand how the pandemic impacted researchers using VRE, we facilitated two focus groups with 12 members of the International Association of Video-Reflexive Ethnographers. The findings suggest the pandemic exacerbated existing methodological challenges, yet also provided an opportunity reflect on our own practices as researchers, namely: accessing sites, building relationships, facilitating reflexive sessions, and cultivating care. Due to public health measures, some researchers used insiders to access sites. While these insiders shouldered additional burdens, this shift might have empowered participants, increased the salience of the project, and enabled access to rural sites. The inability to access sites and reliance on insiders also impeded researcher ability to build relationships with participants and generate the ethnographic insights often associated with prolonged engagement at a site. In reflexive sessions, researchers had to learn how to manage the technological, logistical, and methodological challenges associated with either themselves or participants being remote. Finally, participants noted that while the transition to more digital methodologies might have increased project reach, there needed to be a mindfulness around cultivating practices of care in the digital world to ensure psychological safety and protect participants data. These findings reflect the opportunities and challenges a group of researchers using VRE had during the pandemic and can be used to stimulate future methodologic discussions.

Teacher feedback and student learning: A quantitative study

INTRODUCTION

Feedback plays a significant role in informing students about the outcome of their assessments and contributes to their ongoing learning. The aim of this study was to investigate feedback currently given by clinical teachers to dental students throughout Europe.

METHODS

This study used a piloted questionnaire, delivered on-line to members of the Association for Dental Education in Europe (ADEE). A largely quantitative approach was adopted with multiple-choice, single answer, open text boxes and Likert scale type questions. These data were collected via Google Forms, transferred to an excel spreadsheet and analysed using SPSS software Version 24.

RESULTS

Data were collected from 223 questionnaires completed by respondents from 42 countries. Students received feedback following: (i) formative assessment (70%; n = 155), (ii) summative assessment (88%; n = 196) and iii) informally at any time (85%; n = 188). Feedback was delivered by different people including administrative staff (15%; n = 25). Several methods were used to deliver feedback, including written, oral/spoken, email and individually or as a group. 85% (n = 184) of teachers reported that their teaching had changed following feedback they had received from students.

CONCLUSION

The study showed a strong ethos of delivering feedback from teachers to dental students following both assessment and non-assessment related activities. Teachers should understand/appreciate the individualistic nature of feedback and the importance of cultivating a congenial environment for feedback delivery. Challenges remain in delivering them to a high standard and in a timely manner.

An educational intervention to increase student engagement in feedback

BACKGROUND

The learner has a central role in feedback. We developed a feedback workshop for medical students grounded in two concepts: (1) Student agency in feedback and its interplay in the context of brief clinical attachments; (2) The educational alliance.

AIMS

To determine whether a brief feedback training workshop prior to a series of two-week clinical attachments improves agentic student feedback behaviour (e.g. seeking, recognising, evaluating and utilising feedback) and student satisfaction with feedback.

METHODS

We conducted surveys among three consecutive student cohorts undertaking three fortnightly paediatric clinical attachments. We pilot tested a workshop with Cohort 1 and implemented it for the entire Cohorts 2 (n = 58) and 3 (n = 68). Participants completed the same survey at the start and end of term, with different free-text items. Quantitative and qualitative responses were compared between groups.

RESULTS

Student-reported agentic feedback behaviour increased across all outcomes except for feedback utilisation. Overall student satisfaction with feedback increased during the term in Cohorts 2 (23-65%, p = 0.002) and 3 (40-70%, p = 0.003) but not in Cohort 1 non-participating students (27-42%, p = 0.42).

CONCLUSIONS

A brief one-off student-directed feedback workshop may improve agentic student feedback behaviours (e.g. feedback-seeking) and student satisfaction with feedback.

Using video-reflexive ethnography to understand complexity and change practice

CONTEXT

A range of research methods have been used to understand effective workplace learning in the health professions. The impact of findings from this research usually requires knowledge translation activities in the form of faculty development initiatives, such as supervisor workshops. Far rarer, but with greater potential, are research approaches that concurrently seek to understand and change practice through empowering clinicians to refine aspects of their practice.

METHODS

In this methodological article, we describe video-reflexive ethnography (VRE), a collaborative visual research approach that seeks to capture, illuminate and optimise in situ work and education practices. Video-reflexive ethnography usually has three phases: (a) initial familiarisation with practice through field observations; (b) video-recording of practice, and (c) reflexive sessions about the edited footage with participants and researchers. Drawing on our own experiences as researchers using VRE, we discuss four key principles of VRE: (a) exnovation; (b) collaboration; (c) reflexivity, and (d) care.

DISCUSSION

Although VRE has been used to illuminate and understand health professionals education, its potential for changing clinical education practices has yet to be realised. Video-reflexive ethnography enables observation of the social and relational interactions in health care practice and allows individual (and group) perspectives to be articulated and analysed. The approach can prompt fresh perspectives and insights into health care education and practice for researchers and clinicians through shared deliberations about how practice might be reimagined and enacted.

Ready, willing and able: a model to explain successful use of feedback

Educators have long noticed differences in how students receive and use feedback. Despite the development of best practice guidelines, some learners in the health professions still struggle to incorporate corrective feedback. To date, little research has been done to examine learner characteristics and how those traits might explain differences in feedback-related behavior. A qualitative study using a constructivist, grounded theory approach was conducted to examine the behaviors and learner characteristics that contribute to successful use of feedback. Medical and physician assistant students in their clinical years at one academic health center were interviewed to determine how they used feedback to learn. An overarching theory was developed to explain the process used by students who successfully used feedback. Participants needed to be ready, willing, and able to learn from feedback. Readiness required the learner to hear the corrective feedback without negative emotion and understand how to use the criticism. Willingness required a valuing process that resulted in meaning making. It also required motivation and a growth mindset. Able learners needed to utilize strategic learning behaviors to incorporate feedback into practice change. Barriers to feedback use included emotional interference, inability to create a positive narrative around the feedback encounter and understand it as part of a larger context, and the inability to utilize adaptive learning strategies. The paper considers important education theories, such as Self-regulated Learning and Achievement Goal Theory-theories that should be incorporated into future research.

"It's yours to take": generating learner feedback literacy in the workplace

Feedback can improve students' learning and performance on clinical placements, yet students are often dissatisfied with the process. Attempts to improve feedback frequently focus on faculty development programs without addressing learners' capabilities to engage with feedback. For feedback to be effective, students need to understand its processes and to translate this into practice. Developing student feedback literacy may enhance feedback engagement and, therefore, learning outcomes. This qualitative interview study aimed to problematise student feedback literacy in the healthcare setting, from the learner's perspective. Before commencing placements, 105 healthcare students at an Australian teaching hospital participated in a feedback literacy program. After their placements, 27 students engaged in semi-structured interviews to explore their feedback experiences. Informed by workplace learning theory, interview transcripts were analysed using the framework method of qualitative analysis. Students reported reframing feedback as a process they could initiate and engage in, rather one they were subjected to. When they took an intentional stance, students noted that feedback conversations generated plans for improvement which they were enacting. However, students had to work hard against orthodox feedback expectations and habits in healthcare. They privileged intraprofessional supervisor feedback over interprofessional practitioners, patients, or peers. Findings suggest that student engagement with feedback can be augmented with focussed retraining. However, further research examining the structural and cultural influences on students' capacity to be active in workplace feedback is warranted.

Enriching medical trainees' learning through practice: a video reflexive ethnography study protocol

INTRODUCTION

Supporting medical students' and junior doctors' development in busy clinical settings is challenging. As opportunities for developing trainees, for example, traditional bedside teaching, are decreasing, teaching outside of clinical practice is increasing. However, evidence suggests that effective learning through practice arises via an interplay between, first, what experiences are afforded by clinical settings and, second, how trainees engage with these affordances. Many studies investigating clinician learning through practice focus on only one of these two factors. Yet, a well-recognised methodological challenge of enabling learners to articulate how and what they are learning through practice exists. We need, therefore, to understand how this relationship plays out in practice in ways that enrich learning.

METHODS AND ANALYSIS

This protocol describes a video reflexive ethnographic approach to illuminate how learning through practice in hospital settings occurs and can be enriched. The study will be conducted in two phases. In phase I, senior clinicians from emergency medicine, medicine and surgical specialties will be interviewed about how they guide trainees' learning through practice. These forms of guidance, analysed using the framework method, will inform phase II comprising observations of practice in: (1) emergency, (2) medical and (3) surgical departments. Video recorded episodes of clinicians' guiding learning through practice will be shared and appraised in reflexive sessions with each clinical team. Relational interdependent learning theory informs the design and data analyses to elicit and evaluate strategies for guiding learning through practice.

ETHICS AND DISSEMINATION

Ethical approval has been received from both healthcare and university settings. The findings should provide important insights for clinicians about workplace learning practices. Findings will be disseminated across the project phases and to diverse audiences-locally, nationally and internationally. The dissemination strategy will use seminars, grand rounds, conference presentations and academic papers to articulate practical, theoretical and methodological findings.

Educators' behaviours during feedback in authentic clinical practice settings: an observational study and systematic analysis

BACKGROUND

Verbal feedback plays a critical role in health professions education but it is not clear which components of effective feedback have been successfully translated from the literature into supervisory practice in the workplace, and which have not. The purpose of this study was to observe and systematically analyse educators' behaviours during authentic feedback episodes in contemporary clinical practice.

METHODS

Educators and learners videoed themselves during formal feedback sessions in routine hospital training. Researchers compared educators' practice to a published set of 25 educator behaviours recommended for quality feedback. Individual educator behaviours were rated 0 = not seen, 1 = done somewhat, 2 = consistently done. To characterise individual educator's practice, their behaviour scores were summed. To describe how commonly each behaviour was observed across all the videos, mean scores were calculated.

RESULTS

Researchers analysed 36 videos involving 34 educators (26 medical, 4 nursing, 4 physiotherapy professionals) and 35 learners across different health professions, specialties, levels of experience and gender. There was considerable variation in both educators' feedback practices, indicated by total scores for individual educators ranging from 5.7 to 34.2 (maximum possible 48), and how frequently specific feedback behaviours were seen across all the videos, indicated by mean scores for each behaviour ranging from 0.1 to 1.75 (maximum possible 2). Educators commonly provided performance analysis, described how the task should be performed, and were respectful and supportive. However a number of recommended feedback behaviours were rarely seen, such as clarifying the session purpose and expectations, promoting learner involvement, creating an action plan or arranging a subsequent review.

CONCLUSIONS

These findings clarify contemporary feedback practice and inform the design of educational initiatives to help health professional educators and learners to better realise the potential of feedback.

Identifying coaching skills to improve feedback use in postgraduate medical education

OBJECTIVES

Coaching in medical education has recently gained prominence, but minimal attention has been given to key skills and determining how they work to effectively ensure residents are progressing and developing self-assessment skills. This study examined process-oriented and content-oriented coaching skills used in coaching sessions, with particular attention to how supervisors use them to enhance resident acceptance of feedback to enhance learning.

METHODS

This qualitative study analysed secondary audiotaped data from 15 supervisors: resident dyads during two feedback sessions, 4 months apart. The R2C2 model was used to engage the resident, build a relationship, explore reactions to feedback, explore resident perceptions of content, and coach for change. Framework analysis was used, including familiarisation with the data, identifying the thematic framework, indexing and charting the data and mapping and interpretation.

RESULTS

Process skills included preparation, relationship development, using micro communication skills and techniques to promote reflection and self-assessment by the resident and supervisor flexibility. Content skills related to the specific feedback content included engaging the resident in discussion, ensuring the discussion was collaborative and focused on goal setting, co-developing a Learning Change Plan, ensuring resident commitment and following up on the plan. Together, these skills foster agency in the resident learner. Three overarching themes emerged from the analysis: the interconnectedness of process and content; tensions between encouraging self-direction and ensuring progress and competence; and balancing a coaching dialogue and a teaching monologue.

CONCLUSIONS

Effective coaching by supervisors requires a combination of specific process and content skills that are chosen depending on the needs of the individual resident. Mastering these skills helps residents engage and develop agency in their own professional development. These outcomes depend on faculty maintaining a balance between coaching and teaching, encouraging resident self-direction and ensuring progression to competence.

Drawing on drawings: Moving beyond text in health professions education research

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