Context Ethnography has been gaining appreciation in the field of health professions education (HPE) research, yet it remains misunderstood. Our article contributes to this growing literature by describing some of the key tensions with which both aspiring and seasoned ethnographers should productively struggle. Methods We respond to the injunction made by Varpio et al (2017) that HPE researchers should ground their methodological ventures in their historical and philosophical tenets. To do so, we first review core ethnographic texts that provide a background for ethnographic research in HPE, then provide an orienting definition to bind the specificities of ethnographic research. Finally, we review core theoretical and practical considerations for ethnographic research. Results Ethnography is a slow and deep approach to knowledge production, and as such it requires careful engagement with theory and deliberate choice of methods. Core theoretical tensions include the ontological, epistemological and axiological dimensions of ethnography, and concerns with quality and rigour. Practical tensions include the scope and remit of ethnography, the importance of observing naturally occurring behaviour and the crafting of rich field notes. Conclusions We encourage ethnographers to pursue scholarship that challenges the status quo. Ethnographers should favour deep encounters with research participants, dig deep into the cultural and structural aspects of HPE and be reflexive about knowledge outputs. At a time in HPE when the pressures to publish are high, using ethnography as a research methodology offers an opportunity to slow down and think deeply.

Phenomenon: As a component of self-regulated learning, metacognition is gaining attention in the medical education research community. Metacognition, simply put, is thinking about one's thinking. Having a metacognitive habit of mind is essential for healthcare professionals. This study identified the metacognitive competencies of medical students as they completed a conceptual learning task, and provided insight into students' perceptions of self-regulated learning in their curriculum. Approach: Eleven third-year medical students from a Dutch University were purposively sampled to participate in this qualitative study. The study design included a think-aloud assignment followed by a semi-structured interview. During the assignment, participants were instructed to think aloud while solving questions about medical physiological concepts such as blood flow, pressure, and resistance. Think-aloud data were collected through audiotaping and used to identify participants' metacognitive competencies. The assignment also served as a prompt for an interview in which participants were questioned about metacognitive knowledge, monitoring, experiences, and perceptions of self-regulated learning in their curriculum. All data were transcribed verbatim and analyzed iteratively using a template analysis. Findings: Students differed in their use of metacognitive skills, with an overall focus on monitoring and, to a lesser extent, on planning and evaluation. Additionally, differences were found in students' metacognitive knowledge and metacognitive experiences. There was apparent use of inefficient, superficial predictive cues. Regarding perceptions of self-regulated learning skills, some students felt no need to develop such skills as they perceived medical education as an exercise in memorizing facts. Others emphasized the need for more insight into their actual level of knowledge and competence. Insights: Pre-clinical medical students require explicit teaching of metacognitive skills to facilitate self-regulated learning. Educators should aim to integrate metacognition in the everyday discourse of the classroom to foster an environment in which students discuss their own learning.

Distributing responsibility for patient safety between individual professionals and organisational systems is a pressing issue in contemporary healthcare. This article draws on Habermas’ distinction between ‘lifeworld’ and ‘system’ to explore patient-safety culture in medical residency training. Sociological accounts of medical training have indicated that applying systemic solutions in patient-safety training and practice may conflict with residents’ needs. Residents would navigate safety systems to get their work done and safeguard learning opportunities, acting ‘in between’ the system and traditional processes of socialisation and learning on the job. Our ethnographic study reveals how residents seek to connect system and professional-based learning, and do them together in situated manners that evolve in the course of medical training. We reveal three themes that closely align with the residents’ developmental process of maturing during training and on the job to become ‘real’ physicians: (1) coming to grips with the job; (2) working around safety procedures; and (3) moving on to independence. A more explicit focus on learning to deal with uncertainty may enable residents to become more skilled in balancing safety systems.

Objective: Since physicians behaviour determines up to 80% of total healthcare expenditures, training residents to deliver high-value, cost-conscious care is essential. Residents acknowledge the importance of high-value, cost-conscious care-delivery, yet perceive training to be insufficient. We designed an observational study to gain insight into how the workplace setting relates to residents high-value, cost-conscious care-delivery. Design: This ethnographic study builds on 175 hours of non-participant observations including informal interviews, 9 semi-structured interviews and document analysis. Setting: Department of obstetrics and gynaecology in an academic hospital in the Netherlands. Population or sample: 21 gynaecology residents. Methods: Iterative analysis process of fieldnotes, interview transcripts and documents, including open-coding, thematic analysis and axial analysis by a multidisciplinary research team. Results: Residents rarely consider health care costs, and knowledge regarding costs is often absent. Senior consultants guide residents while balancing benefits, risks and costs, with or without explicating their decision-making process. Identified learning opportunities are elaboration on questions raised concerning high-value, cost-conscious care, checking information about costs that are used in discussions about high-value, cost-conscious care, and having a more open and explicit discussion about high-value, cost-conscious care. Conclusion: Our study emphasizes that the opportunities and potential to train residents to deliver high-value, cost-conscious care in the workplace are present. The challenge resides in capitalizing on these opportunities. We suggest departments to consult external experts to facilitate discussions regarding high-value, cost-conscious care to contribute to informal learning and to create a workplace setting in which high-value, cost-conscious care-delivery is prioritized. Funding: none Keywords: medical education, high-value, cost-conscious care, residency training, ethnography.