Health professions education researchers are increasingly relying on a combination of quantitative and qualitative research methods to explore complex questions in the field. This important and necessary development, however, creates new methodological challenges that can affect both the rigor of the research process and the quality of the findings. One example is "qualitatively" analyzing free-text responses to survey or assessment instrument questions. In this Invited Commentary, the authors explain why analysis of such responses rarely meets the bar for rigorous qualitative research. While the authors do not discount the potential for free-text responses to enhance quantitative findings or to inspire new research questions, they caution that these responses rarely produce data rich enough to generate robust, stand-alone insights. The authors consider exemplars from health professions education research and propose strategies for treating free-text responses appropriately.

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Background: Antiphospholipid syndrome is associated with recurrent pregnancy loss. Low-molecular-weight heparin (LMWH) and/or aspirin (ASA) prophylaxis during pregnancy to prevent future loss is based on limited trial data with mixed results. Objectives: Given the clinical equipoise, we sought to understand how patients and physicians navigate the decision-making process for use of LMWH and/or ASA in pregnancy. Methods: We interviewed 10 patients and 10 thrombosis physicians in Ottawa, Canada from January 2017-March 2018. Patients who met the revised Sapporo/Sydney laboratory criteria with 1 late pregnancy loss or 2 early losses were identified in a Thrombosis Clinic or excluded patients from the TIPPS Study screening logs. Data collection and analysis occurred iteratively, in keeping with constructivist grounded theory methodology. Results: Our analysis generated three themes, present across both patient and physician interviews, which captured a patient-led decision-making experience: (1) Managing High Stakes, (2) Accepting Uncertainty, and (3) Focusing on Safety. Patients and physicians acknowledged the high emotional burden and what was at stake: avoiding further pregnancy loss. Patients responded to their situation by taking action (i.e. using LMWH injections became a “ritual”), whereas physicians reacted by removing themselves from the final decision by “[leaving] it up to the patient”. Conclusions: Our findings should be considered when designing future research on studying the role for LMWH/ASA in this population, as it suggests that the perceived benefits of treatment go beyond improving pregnancy rates. Rather, patients described potential benefit from the process of taking action, even in the absence of a guaranteed good outcome.

Sudden cardiac death (SCD), especially in a young seemingly healthy individual, is a tragic and highly publicized event, which is often followed by a strong emotional reaction from the public and medical community." Although rare, SCD in the young is devastating to families and communities, underpinning our society's desire to avoid any R ESUM E La mort subite d'origine cardiaque (MSOC), en particulier chez une personne jeune et qui semblait être en bonne sant e, est un ev enement tragique et hautement m ediatis e qui engendre souvent de la part du public ou du milieu m edical un « appel à l'action ». La MSOC chez les jeunes, si elle est rare, n'en a pas moins des cons equences The Canadian Cardiovascular Society (CCS) Guidelines Committee identified the need for a Position Statement addressing cardiovascular (CV) screening of competitive athletes with particular attention to the 12-lead electrocardiogram (ECG). Currently, European and American recommendations exist, however the lack of a national position has led to tremendous variation of practice in Canada. 1 This statement provides appropriate, evidence-based recommendations for Canadian sporting organizations and institutions with a focus on the role of routine ECG screening in preventing sudden cardiac death (SCD). Methods and Terminology The CCS Guidelines Committee appointed co-chairs, and a primary and secondary panel to develop this document. The primary panel established its scope, identified topics, reviewed literature, prepared and voted on the recommendations on the

This study elaborates our understanding of how principles of fatigue are constructed and reinforced by the training environment. Whereas fatigue is seen as a collective hazard in other industries, our data showed that, in residency training, fatigue may be seen as a personal challenge. Consequently, fatigue-management strategies that conceptualize fatigue as an occupational threat may have a limited impact on resident behaviour and patient safety.

Introduction The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity. Methods Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April–June 2020. Data were analyzed using constant comparative analysis. Results Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions. Conclusion These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty’s role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.

Objectives Ongoing calls to implement fatigue risk management in residency education assume a shared understanding of physician fatigue as a workplace hazard, yet we lack empirical evidence that all health care team members maintain this assumption. Thus, this study seeks to explore how health care team members understand the role of physician fatigue in an effort to inform the implementation of fatigue risk management in residency training and medical practice. Methods This study uses constructivist grounded theory to explore perceptions of workplace fatigue and its impact on clinical practice. We conducted individual semi‐structured interviews with physicians, nurses and senior residents across four hospitals in 8 different specialties for a total of 40 participants. Constant comparative analysis guided data analysis and led to the final grounded theory. Results While participants outlined multiple problematic manifestations of physician fatigue on clinical performance, they were reluctant to acknowledge any negative impact of fatigue on patient care. We refer to these contradictions as the fatigue paradox. Four key themes sustain the fatigue paradox: the indefatigable physician, blind spots, faith in safety nets and the minimisation of fatigue‐related events. Conclusions This study suggests that health care team members do not universally feel that physician fatigue is problematic for patient care, despite providing multiple examples to the contrary. This paradoxical understanding of fatigue likely exists because the system relies on fatigued physicians, particularly trainees, and provides few mechanisms to critically examine fatigue. Successful implementation of fatigue risk management in residency training may prove elusive if clinical supervisors are skeptical of the potentially negative impact of workplace fatigue.

Context Fatigue risk management (FRM) strategies offer a potential solution to the widespread problem of fatigued trainees in the clinical workplace. These strategies assume a shared perception that fatigue is hazardous. Despite the growing body of evidence suggesting that fatigue leads to burnout and medical errors, previous research suggests that residents perceive fatigue as a personal, surmountable burden rather than an occupational hazard. Before we can implement FRM, we need a better understanding of when and how such problematic notions of fatigue are adopted by medical trainees. Thus, we sought to explore how third‐year medical students understand and manage the workplace fatigue they experience during their first year of clinical rotations. Methods A total of 22 third‐year medical students participated in semi‐structured interviews exploring their perspectives of workplace fatigue. Data collection and analysis occurred iteratively in keeping with constructivist grounded theory methodology and were informed by theoretical sampling to sufficiency. Results Our participants described unprecedented levels of sleep deprivation combined with uncertainty and confusion that led to significant fatigue during training. Drawing on their workplace experience, trainees believed that fatigue posed three distinct threats, which evoked different coping strategies: (i) threat to personal health, managed by perseverance; (ii) threat to patients, managed by faith in the system, and (iii) threat to professional reputation, managed by stoicism. Conclusions Our findings highlight how senior medical students grapple with fatigue, as they understand it, within a training context in which they are expected to deny the impact of their fatigue on patients and themselves. Despite empirical evidence to the contrary, the prevailing assumption amongst our participants is that an ability to withstand sleep deprivation without impairment will develop naturally over time. Efforts to implement FRM strategies will need to address this assumption if these strategies are to be successfully taken up and effective.