Health professions education (HPE) researchers are regularly asked to articulate their use of theory, theoretical frameworks, and conceptual frameworks in their research. However, all too often, these words are used interchangeably or without a clear understanding of the differences between these concepts. Further problematizing this situation is the fact that theory, theoretical framework, and conceptual framework are terms that are used in different ways in different research approaches. In this article, the authors set out to clarify the meaning of these terms and to describe how they are used in 2 approaches to research commonly used in HPE: the objectivist deductive approach (from theory to data) and the subjectivist inductive approach (from data to theory). In addition to this, given that within subjectivist inductive research theory, theoretical framework, and conceptual framework can be used in different ways, they describe 3 uses that HPE researchers frequently rely on: fully inductive theory development, fully theory-informed inductive, and theory-informing inductive data analysis.

No abstract

Previous studies have shown that changes in brain functionClinicians long have observed a lag time of several weeks between the initiation of antidepressant treatment and clinical response for many patients (Hyman and Nestler 1996;Katz et al. 1996). Some individuals do have early symptomatic improvement, and this has been reported to predict further improvement over the next several weeks (Nierenberg et al. 1995). Reports have suggested that some physiologic changes are seen shortly after initiation of treatment (Sulser 1989;Beck 1995;Dahmen et al. 1997). No clinically practical physiologic predictor of treatment response has yet been identified with these techniques, however, and the relationship of early physiologic changes to eventual clinical outcome remains incompletely understood.Quantitative electroencephalography (QEEG) has been used as a physiologic measure in efforts to address these questions. Prior work with "pharmaco-EEG" techniques has shown that the administration of antidepressant compounds yields reproducible changes in EEG activity in healthy control subjects within a few hours of dosing (Saletu et al. 1982(Saletu et al. , 1983(Saletu et al. , 1986(Saletu et al. , 1987(Saletu et al. , 1987 Grunberger 1985, 1988;Sannita et al. 1983;Sannita 1990; Early Prefrontal Changes in Depression 121Itil et al. 1984;Herrmann et al. 1991;Luthringer et al. 1996). The relationship of these immediate EEG changes in control subjects to eventual clinical response in a depressed population is unclear. Other QEEG work with depressed subjects has found that changes from baseline in theta power early in the course of treatment may characterize groups of depressed patients who are more likely to respond to antidepressant treatment (Ulrich et al. 1994). Unfortunately, the overlap in the value of these changes between responder and nonresponder groups precluded the use of this measure in response prediction for individual subjects, and prior research did not indicate how to relate changes in theta power to other measures of regional brain activity (e.g., regional cerebral blood flow or metabolism). We previously have shown that absolute and relative power are complementary measures of brain activity (Leuchter et al. 1993). A relatively new QEEG measure, "cordance," combines information from both absolute and relative power measures (Leuchter et al. 1994a(Leuchter et al. , 1994b. The algorithm yields two indicators: a categorical value ("concordant" or "discordant" state) and a numerical value for each electrode. In an earlier report with the categorical measure , we observed that depressed subjects exhibiting the concordant state prior to treatment had better treatment outcomes when treated with fluoxetine than did subjects with the discordant state. In this report, we use the num*erical values of cordance, because they allow examination of changes in regional brain activity with treatment. In validation against data collected simultaneously with [H 2 15O]-positron emission tomography (PET), cordance values in the the...

Objective Recent studies have found that a subset of young adult survivors of childhood cancer report posttraumatic stress symptoms in response to their diagnosis and treatment. However, it is unclear if these symptoms are associated with impairment in daily functions and/or significant distress, thereby resulting in a clinical disorder. Furthermore, it is unknown whether this disorder continues into very long-term survivorship, including the 3rd and 4th decades of life. This study hypothesized that very long-term survivors of childhood cancer would be more likely to report symptoms of posttraumatic stress disorder, with functional impairment and/or clinical distress, compared to a group of healthy siblings. Patients and Methods 6,542 childhood cancer survivors over the age of 18 who were diagnosed between 1970 and 1986 and 368 siblings of cancer survivors completed a comprehensive demographic and health survey. Results 589 survivors (9%) and 8 siblings (2%) reported functional impairment and/or clinical distress in addition to the set of symptoms consistent with a full diagnosis of Posttraumatic Stress Disorder (PTSD). Survivors had more than a four-fold risk of PTSD compared to siblings (OR=4.14, 95%CI: 2.08-8.25). Controlling for demographic and treatment variables, increased risk of PTSD was associated with educational level of high school or less (OR=1.51, 95% CI=1.16-1.98), being unmarried (OR=1.99, 95% CI=1.58-2.50), annual income less than $20,000 (OR=1.63, 95% CI=1.21-2.20), and being unemployed (OR=2.01, 95% CI=1.62-2.51). Intensive treatment was also associated with increased risk of full PTSD (OR=1.36, 95% CI 1.06 -1.74). Conclusions Posttraumatic stress disorder is reported significantly more often by childhood cancer survivors than by sibling controls. Although most survivors are apparently doing well, a subset report significant impairment that may warrant targeted intervention.

Purpose Entrustable professional activities (EPAs) are a hot topic in undergraduate medical education (UME); however, the usefulness of EPAs as an assessment approach remains unclear. The authors sought to better understand the literature on EPAs in UME through the lens of the 2010 Ottawa Conference Criteria for Good Assessment. Method The authors conducted a scoping review of the health professions literature (search updated February 2018), mapping publications to the Ottawa Criteria using a collaboratively designed charting tool. Results Of the 1,089 publications found, 71 (6.5%) met inclusion criteria. All were published after 2013. Forty-five (63.4%) referenced the 13 Core Entrustable Professional Activities for Entering Residency developed by the Association of American Medical Colleges (AAMC). Forty (56.3%) were perspectives, 5 (7.0%) were reviews, and 26 (36.6%) were prospective empirical studies. The publications mapped to the Ottawa Criteria 158 times. Perspectives mapped more positively (83.7%) than empirical studies (76.7%). Reproducibility did not appear to be a strength of EPAs in UME; however, reproducibility, equivalence, educational effect, and catalytic effect all require further study. Inconsistent use of the term “EPA” and conflation of concepts (activity vs assessment vs advancement decision vs curricular framework) limited interpretation of published results. Overgeneralization of the AAMC’s work on EPAs has influenced the literature. Conclusions Much has been published on EPAs in UME in a short time. Now is the time to move beyond opinion, clarify terms, and delineate topics so that well-designed empirical studies can demonstrate if and how EPAs should be implemented in UME.

Purpose Since 1995, the David Geffen School of Medicine at UCLA (DGSOM) has created policies to prevent medical student mistreatment, instituted safe mechanisms for reporting mistreatment, provided resources for discussion and resolution, and educated faculty and residents. In this study, the authors examined the incidence, severity, and sources of perceived mistreatment over the 13-year period during which these measures were implemented. Method From 1996 to 2008, medical students at DGSOM completed an anonymous survey after their third-year clerkships and reported how often they experienced physical, verbal, sexual harassment, ethnic, and power mistreatment, and who committed it. The authors analyzed these data using descriptive statistics and the students’ descriptions of these incidents qualitatively, categorizing them as “mild,” “moderate,” or “severe.” They compared the data across four periods, delineated by milestone institutional measures to eradicate mistreatment. Results Of 2,151 eligible students, 1,946 (90%) completed the survey. More than half (1,166/1,946) experienced some form of mistreatment. Verbal and power mistreatment were most common, but 5% of students (104/1,930) reported physical mistreatment. The pattern of incidents categorized as “mild,” “moderate,” or “severe” remained across the four study periods. Students most frequently identified residents and clinical faculty as the sources of mistreatment. Conclusions Despite a multipronged approach at DGSOM across a 13-year period to eradicate medical student mistreatment, it persists. Aspects of the hidden curriculum may be undermining these efforts. Thus, eliminating mistreatment requires an aggressive approach both locally at the institution level and nationally across institutions.

Purpose This study explores an under-investigated topic, how medical residents experience shame within clinical learning environments, by asking residents to reflect on (1) the nature of their shame experiences; (2) the events that triggered, and factors that contributed to, those shame experiences; and (3) the perceived effects of those shame experiences. Method In this hermeneutic phenomenology study, the authors recruited 12 (self-nominated) residents from an internal medicine residency at a large teaching hospital in the United States. Data collection from each participant in 2016–2017 included (1) a written reflection about an experience during medical training in which the participant felt “flawed, deficient, or unworthy,” and (2) a semi-structured interview that explored the participant’s shame experience(s) in depth. The data were analyzed according to hermeneutic traditions, producing rich descriptions about participants’ shame experiences. Results Participants’ shame experiences ranged from debilitating emotional and physical reactions to more insidious, fleeting reactions. Participants reported shame triggers relating to patient care, learning processes, and personal goals; numerous factors contributed to their shame experiences. The effects of shame reactions included social isolation, disengagement from learning, impaired wellness, unprofessional behavior, and impaired empathy. Positive effects of shame reactions included enhanced learning, increased willingness to reach out for help, and improved relationships. Conclusions Shame reactions can be sentinel emotional events with significant physical and/or psychological effects in medical learners. This study has implications for learners, educators, and patients, and it may pave the way toward open, honest conversations about the role shame plays in medical education.

This interview technique proved to be reliable and was seen as transparent, uniform, and fair. The predictive validity of this process remains to be determined.