The PAPERs Podcast

Episode host: Linda Snell.

Episode 68 transcript. Enjoy PapersPodcast as a versatile learning resource the way you prefer—read, translate, and explore!

---

Episode article

Hu, W. C.-Y., Nguyen, V. A. T., Nguyen, N. T., & Stalmeijer, R. E. (2023). Becoming Agents of Change: Contextual Influences on Medical Educator Professionalization and Practice in a LMIC Context. Teaching and Learning in Medicine, 35(3), 323–334.

Background

In Low- and Middle-Income Countries (LMIC), health workforce shortages and increased expectations of quality care have led to a rapid growth of medical schools (size, number, global outlook). This leads to a need for medical educators, with the demand for medical education expertise met by migration, transnational medical program partnerships, and international aid, including faculty development projects initiated by institutions in high-income countries.  

As in high income countries, medical educator professionalization (with graduate degrees, specialized units, professional associations) has emerged in LMIC.  

Professionalization is also related to having a professional identity, displayed as a ‘presentation of the self within the workplace’ (how you see yourself and how others see you), however variations between workplace contexts are usually not considered, and educator professionalization has rarely been studied in LMICs. Whether and how all this relates to faculty development programs originating from outside LMIC contexts is unknown.  

The Theory of Practice Architectures “holds that practices are composed of sayings, doings, and relatings that hang together in the purpose of the practice. In turn, these sayings, doings, and relatings are enabled, constrained and made possible by cultural-discursive (i.e. professional and organizational discourses and values), material-economic (i.e. institutional physical resources and activities), and social-political (e.g. institutional and professional relationships and roles) arrangements found in or brought to the site where the practice occurs.” (Kemmis) 

Methods

Constructivist paradigm.  

Qualitative interviews looked at the experiences of 8 Vietnamese medical educators in the 10 years following their completion of the Maastricht MHPE program. 

Questions adapted from an international research program on medical education careers (like Varpio et al.) asking about career pathways of medical educators, structure and function of Medical Education Units, recognition of Medical Education.  

Used the Theory of Practice Architectures as a lens to analyze the data, focused on contextual factors influencing educators’ self-reported professional practice post-MHPE to look for what shapes practice and professionalization within their context and the impact of context on education practice.  

Interviews in Vietnamese, questions translated and backtranslated.  

Initial analysis done in Vietnamese, inductively identified themes and supporting quotes. These also were translated to English, then backtranslated.

Results/Findings 

The authors identified four themes:  

• Careers and Practices: What they did before, during, and after the program; roles as teachers and education leaders…but none promoted to full prof and none doing education scholarship.

• Unrecognized and Unseen practice: The lack of official recognition led to professional invisibility, affecting promotion and motivation.

• Structural Restraints: Limited resources and weak institutional structures hampered individual advancement and collective efforts. 

• Cultivation of Connections: Social traditions and hierarchical structures resisted change, though some educators took personal initiative to build networks and influence change.

Participants reported being in well-established teaching delivery roles. However, the absence of professionalizing discourses and material resources meant that practice was restricted and determined by institutional leadership and individuals’ adaptations. 

Participants reported limited formal recognition and material support of their potential as educators upon reintegrating into Vietnamese medical education, whereas preexisting roles as clinicians were more highly valued. Participants’ fragile new educator identity and agentic repertoire could be overwhelmed by external, structural restraints (e.g., institutional leadership directives) or—as evidenced by signs of interviewees’ emergent agency—reinforced by their personal initiative to cultivate connections and change. The discussion also links the findings to the broader socio-cultural and political climate. 

Conclusions 

The authors say their “findings suggest that faculty development delivered across diverse contexts, such as in distributed or transnational medical programs, may have more effect if informed by a practice architectures analysis of each context” 

Contextual factors necessitate the co-design and co-delivery of international faculty development programs if they are to achieve lasting impact in LMICs.Emphasize the importance of attention to understanding local cultural context. 

Paper clips 

Interesting application of the Theory of Practice Architecture to evaluate the outcomes of a faculty development program, with important implications for designing activities for medical educators taking into consideration meso and macro dynamics. Use of “an established methodology in a new and underexplored context.

Study has an impact on practice as well as theory. The material is presented in a way that can influence educational decision-making.

Laras Book tip

Exploring Education and Professional Practice: Through the Lens of Practice Architectures, 2016(ResearchGate)
Written by Kathleen Mahon, Susanne Francisco, and Stephen Kemmis.

---

Transcript of Episode 68

This transcript is made by autogenerated text tool, and some manual editing by Papers Podcast team. Read more under “Acknowledgment”.

Jason Frank, Lara Varpio, Linda Snell, Jonathan Sherbino.

Start

[music]

Jonathan Sherbino: Welcome back to the Papers Podcast where the number needed to listen is one. It is the start of the academic year. Well, it started the academic year here in North America. It is fall. My kids are off to school. They were crying. I was cheering. You can figure out why. Lara’s here. She has a T-shirt. I’m going to let her display it for all of you. Go ahead, Lara.

Lara Varpio: Hi, everybody. How you doing? I don’t need to tell them what my T-shirt says, do I? They say I have two problem or I can’t read it. It’s backward in my screen.

Jonathan Sherbino: I’ll read it for you.

Lara Varpio: Thank you.

Jonathan Sherbino: Lara’s T-shirt says they say I have two major flaws. I don’t listen. Something else.

All right, Jason. Thankfully, you’re also wearing a T-shirt.

Jason Frank: Stop. I’m in a suit.

Jonathan Sherbino: How are you?

Jason Frank: I’m in a tux. I’m great. Hey, hi, everybody. Thanks for joining us.

Jonathan Sherbino: Linda, save us from ourselves. We’re going to be really funny to ourselves, but everybody else is going to unsubscribe from this podcast because the inside jokes are too deep. What do you have for this week?

Linda Snell: Okay. Well, the first thing I have is I’m not going to fall into the error that Lara did, which is trying to remember at the end of the podcast what our contacts were. So I’m going to say right up front, if you want to get in touch with us, Jason, would you stop yawning, please?

Jason Frank: That was my tribute to you. This is your go-to, right? So it’s like, it’s my Linda tribute.

Linda Snell: All right, let’s get to the paper. Before I give you the topic and the title, let me ask you to describe very briefly some teaching or some other education practice that you’ve done, which was not effective or successful, as the context was different than what you were used to. And We’ll go Jon, Jason, Lara.

Jonathan Sherbino: So I worked for a year in low and middle income countries as a physician, but it was extremely early in my career. And I had no understanding of the good principles of teaching or fanciness, as I might say, of pedagogy.

And so I delivered a lecture using a chalkboard to a nursing class that had physiology completely irrelevant to the context. And imagined that this class of nursing students would somehow engage and interact with me. And this is, here’s a live recording of when I’d ask a question.

[silence]

Jonathan Sherbino: There we have it. That’s exactly when it didn’t work. One, I had the wrong instructional method. Two, I had the wrong content. And three, I never attended to cultural or contextual needs. Of the audience and of the educational purpose of the teaching opportunity. So yeah, wow, you can only get better from there.

Jason Frank: I once did a teaching session. I was visiting a professor in a country in Asia and did a teaching session, did my go-to Canadian teaching moves from Canadian medical students, lots of interactivity and enthusiasm. And just like Jon, silence, because it was not culturally appropriate locally. To speak up in the way that I was asking the class to. So that was on me for not adapting my teaching technique, for sure.

Lara Varpio: Yeah, so mine is similar. I was a visiting professor in Taiwan. And can I just say I had such a great time there? And what an excellent set of community members. And it was so rich and it was so fun. And I was really lucky because the person who invited me, Lynn Monrouxe, can I just… Put a little shout out to Lynn and Charlotte Reese because their work is epic.

Lara Varpio: And if you haven’t read Lynn Monrouxe and Charlotte Reese, you’re missing out on a great set of readings. But anyway, Lynn had prepared me and warned me that because I was doing a lot of teaching in different contexts. And she’s like, don’t don’t come with a North American attitude.

Lara Varpio: You’re going to have to flip the script. And even though I tried to, I only met with partial success. I ended up having to start sessions by not teaching. It was the weirdest. It was really hard for me to try to adopt that approach. And it just made me really respect the work that people do to do work across cultures. I was just really humbled.

Linda Snell: So I too have had experiences, and obviously I’ve had more than one, so I haven’t learned from them, where I’ve tried to interact and I’ve got the same reactions of silence. But the other thing that happened to me was I was teaching in a place where people closed their eyes, and I was convinced that they were sleeping and that I was really… Sleep. Boring. And it turns out that…

Lara Varpio: Not good.

Linda Snell: Not good. But it turns out that in that particular context, people actually close their eyes so they can concentrate. So that’s what they told me anyway. I didn’t hear them snoring. So all to say that context is really important. We’re going to talk about a paper called Becoming Agents of Change: Contextual Influences on Medical Educator Professionalization and Practice in a LMIC Context.

On medical educator professionalizations and practice in a low and middle income country context. 2023 in Teaching And Learning In Medicine, Wendy Hu, Van Nguyen, Nga Nguyen, and Renée Stalmeijer. I’m entitled this episode, Medical Educators are Medical Educators, right? Or maybe not. So a little bit of background here.

Low and middle income countries have as we do, but perhaps more so health force, workforce shortages, and at the same time, increased expectations of quality of care. So therefore, they’ve had a rapid growth of medical schools and other health profession schools, both in terms of size, number, and they’re global.

Therefore, as we go down this path, there’s a need for medical educators who can both teach and plan curricula or whatever. And with this has come a demand for medical education expertise, and it’s been met by migration, as in, for instance, Lynn Monroux going to Taiwan, as you talked about.

It’s been met by transnational program partnerships, and it’s also been met by international aid, including faculty development projects that were initiated by institutions outside the region in high-income countries.

So as you can imagine… There might be some problems with this. So as in high-income countries, medical educator professionalization, which could be from graduate degrees, from special units, from having professional associations, has emerged in LMICs.

And professionalization is also related to having a professional identity, which can be displayed as what the authors here call a presentation of self within the workplace. What I say is that how you see yourself and how others see you.

However, variations between workplace contexts, especially high-income and LMICs, has rarely been studied. Whether and how all this relates to what I would call imported faculty development programs originated outside the LMIC context is unknown. And an example of that might be, for instance, Vietnam sending future clinician educators to Maastricht for a graduate program, just as an example.

I’m going to sideline here just for a second to talk about the theory of practice architectures, which is what the underlying theory is, the sensitizing theory that these authors use. The theory of practice architectures, and I quote here from the person who seems to have written a lot about it, someone called Chemis, is that practices are composed of sayings, doings, and relatings.

That hang together for the purpose of practice. So what does that mean? Saying, doings, and relatings are related and constrained by three things, cultural and discursive elements, such as professional and organizational discourses and values. That’s something that I might call the hidden curriculum.

Material and economic issues, such as the actual resources and activities that are done, and socio-political activities. Or arrangements such as institutional relationships, organizational structures. And all of this influences where the practice happens and how it happens. So just think about that as we go forward.

So the authors say that the purpose of their study was to investigate contextual influences of the long-term impact of an international faculty development program a decade after its delivery in an LMIC. Context, in this case, Vietnam. And the authors did this by examining the experiences of Vietnamese medical educators in the decade following their master’s completion. So does this grab you, Jason, Jon, Lara?

Jason Frank You’re going to hear me say lots of positive things in this episode about this paper. This completely grabs me.

The theory of practice architectures is something I was briefly exposed to before, and this paper made me go and read about it, and I see its utility. And it relates… So much to so many things that we try and implement in MedEd. So that’s my little foreshadow that I really like this paper because it just… Highlighted the problems of implementation.

Jonathan Sherbino: I’m pausing here because I have to foreshadow a little bit of my challenges with this paper as we move forward. I want to know what it looks and feels like to be a medical educator in an LMIC where you don’t have all the resources and you may not have all the cultural and social contextual pieces that validate it. Certainly in Canada, which is the context for me, being a medical educator is still a valid professional identity in the institution but it may not be at the same level as some leadership in research like biomedical research positions so I do want to know what it feels like in this country of Vietnam I think the their transfer is saying we’re going to talk about LMIC’s i think they should just say well what it looks like in Vietnam because that’s really all but so i’m like that but the way they set up the this is the methods as we’re going to hear about, I don’t think it answers that question.

And so I’ll save my critique for when we get to the methods part.

Lara Varpio: And I just want to double down on the idea of theory practice architecture. This theory is, this might be my new favorite theory. This is one of the ones that after I read this paper, and of course, because you know, I’m going to go read all the citations. I’m in love. It sits underneath the umbrella of theories called practice theories. I’m not going to go into it too much, Linda, because you’ve already talked about it.

Lara Varpio: But when they bring this theory to the study, the theory helps us to explore how the practices of medical education in Vietnam are shaped by a particular set of discourses, and they hang together with a particular set of actions and a particular set of social relationships. And when you look at decisions in that broader way of thinking, it just really helps you to understand complexities.

Lara Varpio: Involved in decision making and actions in different ways. If you want to know more about this theory, I think I shared it with you, Linda, but I can make sure you have it. I have a citation from Kathleen Mahon, who wrote a beautiful introduction to practice theory in a book, and it’s just gorge. So there’ll be a nice little reference to that in the show notes.

Jonathan Sherbino: So if you’re playing along at home, Lara has gone from theory promiscuity to true love. Okay. All right. I like it.

Lara Varpio: Maybe it’s just sequential monogamy.

Jason Frank: Actually, before we move on, this is really important for listeners.

Lara Varpio; No, monogamy is not really important for listeners.

Jason Frank: Oh, not this part.

It’s not about you. Good. How do you learn a new theory? I’m curious, Jon, Linda, Lara.

Jonathan Sherbino: I think I encounter it in some context, and he’s using the context of reading a paper and me saying, oh, this is something I haven’t heard about. And we’ll then do some kind of exploration of it. So it’s not with a pull, it’s with a push. So I bump into it and that forces me to understand where it’s going. And a reminder that there is such a diversity of theories.

Jonathan Sherbino: There’s not a hierarchy. There’s not a limited boundary. We talked on a previous episode about how one theory was adopted and moved into a very different context. And so that’s maybe the richness, but also the challenge of health professionals education. There is a… Whole spectrum of theories we can draw. All right.

Linda Snell: I didn’t know whether that was a L Lara or L Linda, but anyway. Like Jon, I look up theories from my reading, but I also get theories when I’m working with colleagues who come from a different perspective, who say, you know, this theory might work when we’re trying to answer this question. And it can be either co-investigators or in my group, it can actually be colleagues when we bounce ideas off each other.

Lara Varpio: And so for me to learn a theory, often it starts with a push, with a paper pushes me to go somewhere. But it’s also, as Linda pointed out, the great fortune I have of working with different people. And also, I’m a theory nerd. So I buy books about theory, because, you know, they’re hot off the press, in case you didn’t know there was a whole section of the press that you can be hot off of for theory.

Lara Varpio: The other thing, though, is that I also recognize that theories are really hard for listeners to… To know which theory is relevant, how it works, those sorts of things. So, you know, small plug, I’m working with some authors being led by Megan Brown and Gabs Finn and Nani. And what we’re doing is we’re putting together a book of 100 different theories that might be relevant to medical education.

Lara Varpio: Because, you know, there’s ones that we use often, and you can get some pretty good summaries for that. But what about the ones we don’t use often? We don’t see often. So We’re putting together 100 theories that might be relevant. Sincerely, let’s talk about the theory rabbit hole that I am loving with every entry. I’m having the best time ever.

Linda Snell: Okay, let’s go on and get back to this paper.

What were the methods? Well, you’ll be pleased to know, Lara, that there was a paradigm. There was a constructivist paradigm that they state up front.

The authors did qualitative interviews looking at the experiences of eight Vietnamese medical educators in the 10 years following their completion of the master’s program at Maastricht.

There were more who had completed the program, but they had moved off to do other things. So they got all of the ones who were remaining. The questions were adapted from an international research program on medical education careers. Somebody called Varpio was an author in that.

And it asked about career pathways of medical educators, the structure and function of med ed units, and the recognition of medical education in that context. So Lara is a doctor. Making little hearts on the screen now.

They used the theory of practice architectures as a lens to analyze the data, and they focused on the contextual factors that influence educators’self-reported professional practice following their degree to look for what shapes practice and professionalization within their context and the impact of context on their education practice.

A couple of things which… I initially didn’t find all that unusual, but Lara has pointed out that it might be. The first is that the interviews were done in Vietnamese, so the questions were translated and then back-translated. And secondly, the initial analysis was done in Vietnamese, inductively identifying themes and supporting quotes, and these were also translated into English and then back-translated.

Now, living in a bilingual area and working with students from many areas of the world. Back translation is something which is kind of bread and butter to me, but it might not be to some of our listeners. So, Lara, would you like to talk about it?

Lara Varpio: Sure, I can say a few words about back translation because when you work with data, then it’s in a language that’s not your own or not one that you speak fluently. You need to translate the data, and especially if your colleagues and your collaborators don’t speak that language.

Lara Varpio: However, as we all know, translation has a lot of room for interpretation. So I thought I’d come up with an example. And as you all know, I speak English, French and Swedish. But in Swedish, in English, let me start there. In English, we have the word I think. I think we should do this. I think we should do that.

Lara Varpio: Swedish has three words that for the life of me all mean think. And I have no idea when to use which. So they have tänker, tycker and tror. So and each they mean different ones like I believe and ones like I logically deduced and the other one I don’t know what it means. But they all like in my brain that sits under the category, I think. Right.

Lara Varpio: So when I speak Swedish to my Swedish family, I’m like, blah, blah, blah, blah, blah, talking away. And then I want to say, I think we should do something. I’m like, I just put them all in there because it’s like you pick which one you think is right. But the point being that when you’re translating data back and forth. It really makes a difference if they say, I believe, or I logically deduced, or those sorts of things.

Lara Varpio: Like, that’s part of the richness of the data, and you can’t lose that because in your brain, you’re summarizing all of it under think, right? So, this back translation is when you start in their native language, you translate it into, for instance, English or the language of the research team, but then you don’t stop there.

Lara Varpio: You translate back into the native language, and you give it to a native speaker to say, is it the same? Did we capture it? Did we? Did we make the right word choice between tanker, tykker, and trur? So if we use back translation that way, we have an opportunity to make sure that we can get data from different contexts and make sure that we keep the meaning as close as humanly possible to the original.

Jason Frank: Very cool. I think tanker, trur, and trur are all in the Hobbit. I think those are all.

Lara Varpio: They’re all Hobbit terminology. Absolutely.

Jonathan Sherbino: There goes our Swedish audience.

Jason Frank: Why? It’s great names.

Linda Snell: Yes, it’s your pronunciation, Jason.

Jason Frank: I know.

It’s so accurate.

Linda Snell: Yeah. So briefly, comments on methods, Jason, Jon, Linda?

Jason, no, not Linda.

Jason Frank: That’s awesome.

I’m really curious to hear what Jon’s beef is with the methods. I do recognize that they have two research questions, and one of them, I just think it’s a wording thing. It isn’t actually answered in this paper. What I think they meant to say was what happened to their careers in this context, as opposed to what professional development did they do?

Because I don’t think they answered that at all. I thought this was fine. And I thought the use of the theory of practice architectures was a real strength of this paper. One thing that was missing was a diagram.

That explains the theory at a glance, because otherwise it requires every reader to go down a Varpio rabbit hole to make sure they’re really familiar with how they’re using this theory. In order to understand the paper, I had to read it a couple times before I was really enamored with the paper.

Jonathan Sherbino: I thought their analysis of their data was fine. And I think they get full marks for that. I have two problems. One is I can’t figure out their conceptual framework. Their chain of logic.

Their question is, what are the practices and professional development of medical educators in Vietnam? And how is medical education practice shaped using this theory of cultural, material, economic, socio-political?

And they define medical educators from a very loosey-goosey kind of definition, which is people committed a significant amount of their time, energy, and professional development in medical education can demonstrate this become an important component of their career. That is so nonspecific. I think it spills.

So what I feel reading there until I get into the methods is we’re going to talk about what does it feel like to be a medical educator in Vietnam? Then they choose people that were part of this initiative as part of an international development aid project where they said, we’re going to take two people from the eight medical schools in Vietnam and send them to do master’s work and then bring them back.

And we’re going to ask them 10 years later, how did it work? Which is more like a program evaluation.

And so what you haven’t done is you haven’t tried to sample across all the individuals who might be medical educators under your very loose definition to say, okay, do we have a sample that’s representative of everybody who is defining, self-defining, because that’s what the definition looks like as a medical educator in Vietnam. So we don’t have that.

We then instead have… Individuals from this program. So it starts to feel like, am I doing an evaluation of the program? Was it a success? Now, Jason, you’re waving your hands because I have a second thing to say, but jump in.

Jason Frank: Okay. So that I had the same thought when I read it the first time. So I have a little tiny bit of context and I’m open to correction for the following paragraph, but I was in Vietnam last year and I was really struck by the people who were at this MedEd conference that my colleague, David Duong, invited me to be at.

And some people in that room, they sort of had the identity and title and career path of medical educator. And what they were explaining to me was the vast majority of doctors and health professionals in Vietnam don’t see themselves as having that role, that identity, that obligation. They might work in a clinical setting where there are learners, but they don’t feel obligated to teach the way these other people do.

So my interpretation now is of this paper. Is they’re saying, hey, this is not a program evaluation. They explicitly say that in their discussion. They say, hey, this intervention happened that tried to create a bunch of medical educators in their context. What happened? And I think that’s the paper, and it made more sense to me then.

Linda Snell: I think if you just remember that identity is how you see yourself and how others see you, it’s helpful.

Jonathan Sherbino: I have a question about data collection and I think it’s not sufficient. So remember, there’s 16 people in the cohort that go and do this master’s program and then come back. When they go to do the study, eight have left medical education in all ways. So they’re down at 50% and then of their remaining eight, two of them are actually retired.

So you only have six who are actually still in practice and we’re going to hear a little bit more about their demographics. And so now… You have six in-practice individuals, maybe eight out of a cohort of 16, that are going to help answer the question of, what does it feel like to be a medical educator in Vietnam? I don’t think that’s sufficient.

I don’t think you have the data. They do great work with the analysis, but I don’t think we have sufficiency to make some of the claims or make some of the interpretation that is going to follow along. So I’m bothered by their conceptual framework. I’m not sure what’s happening there. And that’s what the big hiccup I have.

Lara Varpio: What I’m going to add to this conversation is going to be really short because my point is actually about the program evaluation, but I can’t talk about that until we get through results. So I’m just going to hold on to that point because I know it’s not a program evaluation, but I have thoughts.

Lara Varpio: The other thing that I just want to say from a methodological orientation and from the design of the study, the study design’s tight. The approach is tight. It’s a small scope study. That’s fine. I will agree with you, Jon, that given the…

Lara Varpio: The orientation of trying the kinds of critiques they end up making in the discussion section. I do think that your point is really well made that the population that they sampled is probably a very, it would have been really rich to get different perspectives and more voice. Now, that said, the resources to do a bigger, broader study are not infinite, the time and energy.

Lara Varpio: And as we’re going to hear about in this context, it’s not necessarily, you know, there’s a gorgeous paper out there. That talks about medical education as the ugly duckling. And that’s what you’re going to see in these results.

Lara Varpio: And so when we ask about getting more people and those sorts of things, part of the challenge is that there is going to be some real restrictions about access and who identifies and all those sorts of things. So I’m going to hold on to my bigger comments for later. So Linda, I’ll pass it back to you.

Linda Snell: So thank you all for your comments on methods. Let’s go into the results. Jon has pointed out the demographics of the people who they actually interviewed. There were four themes, and I won’t say four themes that emerged, because I know Lara doesn’t like that. But in the paper, they talk about themes that emerged and things that emerged, just so you know, Lara.

The first had to do with career and practices. So what the educators did before, during, and then after their program. And what they found was that they did have roles, as Jason pointed out, as teachers and education leaders. But. None had been promoted to full professor, and none were doing education scholarship, for whatever that’s worth.

Maybe that wasn’t considered part of their role or wasn’t valued. Secondly, something that the authors called unrecognized and unseen practice. There was a lack of official recognition that was conferred on them. There was subsequent invisibility, and that impacted not only positive things like promotion, but also motivation, which may have been why. Half the people dropped out.

Third, structural restraints, resource limitations, lack of institutional structure, lack of med ed units, lack of physical resources and financial resources affected both individual advancement, but also collective activity, people working together. And if you don’t have that community of practice, it’s a little difficult to go forward.

And finally, cultivating connections through what they call social traditions and the fact that they had a hierarchy that actually resisted change.

So to try and summarize those four things without going into all the details, participants reported being in well-established teaching delivery roles, but the absence of resources meant that practice was restricted and determined by institutional leadership. Problems and individual adaptations. There was this limited formal recognition and material support. So they had trouble reintegrating into Vietnamese medical education.

Whereas their pre-existing roles as clinicians was highly valued. So again, it has to do with the stature of med ed. And the authors called their identity a fragile educator identity, where agency could be overwhelmed by all kinds of external structural restraints, or it could be reinforced by their personal initiative to cultivate connections and change.

There’s several paragraphs near the end that also link the findings to the broader sociocultural and political climate, which Jason has reported a little bit.

So in conclusion, the authors say their findings suggest that faculty development delivered across diverse contexts, such as in distributed or transnational medical programs, may have more effect if informed by a practice architecture analysis for each context.

In other words, contextual factors necessitate the co-design and co-delivery of international faculty development programs if they’re going to achieve long-lasting effects.

Authors several times in the paper emphasize the importance of attention to understanding local cultural context. So quick take on your thoughts on this. We’ll go, Lara, Jason, and Jon.

Lara Varpio: I have two points I just want to make really quickly, Linda. Thank you for letting me go first, because I love having the first word when it comes to these things. Just so you know. Thank you.

No, the only two things I want to point out, Linda, first of all, is that I think, you know, what’s really interesting is that I don’t know the history necessarily behind this paper, but I could imagine it started as a program evaluation to see how successful the Vietnam program of sending people to Maastricht was.

And what’s fascinating is that if they have done a typical program evaluation, they could probably would have found out everything. They probably would have said, therefore, we met the objectives set out by the program.

And everybody would have said, therefore, it’s successful. However, as this study shows us, the program probably should not be labeled successful. Sure, the education was delivered. Yes, degrees were bestowed. But when they back home, the degree didn’t carry weight.

And as these authors explained, the practice architecture needed in Vietnam for these degrees to carry weight wasn’t there. So What I really appreciate about this work is that they took something that could have been a very, it could have been a program evaluation that did a surface level program evaluation and said, therefore, the program’s great.

Instead, what they did is they did a deeper, more thoughtful, broader examination of what happened as a result of the program. So I’ve got a lot of respect for that.

The other thing I just want to say is that the authors critique a body of work about health professions, education, scholarship units as organizational bodies in medical schools and Specifically, they talk about how framing these units and the people who lead them as institutional entrepreneurs is an idea that works in Western countries, and it doesn’t hold for Vietnam.

So just for the sake of clarity, I’m the lead researcher in that body of research, and there’s like nine, ten, whatever papers.

But the critique these authors make is 100% right. The research that we did on units was based in Canada, US, Australia, New Zealand. That was the confines of the study.

And these authors make an incredibly important point that’s important for all of us to recognize that our HPE work, our med ed work is always limited by a variety of, for a variety of reasons and in a variety of ways, and not the least of which is really important for us to remember.

Medical education, quite frankly, in my mind is more of an art than a science. There’s more room for interpretation and context matters and all those sorts of things, as opposed to a science where we might say there’s an answer that is right.

And so I really appreciate the critique from these authors that we need to be thinking about the work that we do. And in this case, the educational programs we deliver in terms of the context where the people are who are going to harness, use the data, the findings, the programs.

Because as this research shows us, the program goals and expectations that were set out for a Dutch context or by a Dutch context when it went to Vietnam. The learners walked away with a very different orientation.

Jonathan Sherbino: Thanks, Linda, for giving me the last word, because I prefer that to the first word.

I found the results to be kind of like a chimera. If we’re looking at it through the faculty development lens, which they said we’re not doing it, but that’s their big point in their discussion, not shocking that you take people out of their context and put them into a program that is not recognized within their home environment. And then distribute them so they’re all by themselves across the country.

And that’s the sum total of your innovation or your inoculation. Not surprisingly, you’re not going to see a significant movement or change in the system a decade out. That’s not surprising. I think we’d all agree with that. What I think is more challenging in the other version of their study is, man, it’s really invisible and really lonely to be an educator in Vietnam.

And it pays bad and it’s hard to do the work because you’re not, none of them are involved in scholarship. I think we skipped over that pretty quickly. So you’re not even advancing your own field or creating innovation that is being disseminated so that you can have a transformation even within your own context, or at least not how it’s reported amongst the six people still in designated roles.

And not all of them are actually in specific education roles. So again. It feels pretty lonely. I will put a big caveat, but I don’t think we can transfer their findings in a big way, even within the context of Vietnam, because I think there’s a whole bunch of other voices that haven’t been heard.

So I don’t want to have any definitive conclusions. I’d leave that as a very soft conclusion, but as an opportunity to move forward.

Jason Frank: Okay. So I know we’re tight for time, but I found this paper really, really rich. I found the findings resonated deeply with me, and I’m going to compare it to two things really quickly. One is… The program that I think got both Jon and I into MedEd was a fellowship program in our region. And it was premised on the fact that there were very few medical educators actually using theory.

They gave a little bit of money to a few trainees and others and then said, go have a great career. When we followed up with people, they said things like, that was amazing, was inspiring when we’re all together. But when I went back home, my department head said, here’s some patients to see.

So these are recurring themes, I think, worldwide around infrastructure and recognition and so on. What a contrast it is to people who are doing quality improvement. And that’s a very young field. And there are colleagues that are getting expertise. They’re getting people who teach quality improvement, people who execute quality improvement.

And I feel like their recognition is coming to them a little faster than our field. And that just really, that contrast really makes me think about what the differences are worldwide. This paper, I actually think, is filled with lessons. I disagree with Jon. I think it’s highly valuable. It’s not just about Vietnam. It’s like, if this, then that. There’s a whole bunch of really good lessons.

Linda Snell: Maybe some of the lessons we need to learn are also that your description, Jason, is probably where we all were some decades ago. And how have we moveocd on with our context and how can that be expanded?

One quick paperclip before we have our highly validated, sorry, I’m not supposed to say that. One quick paperclip, the application of the theory of practice architectures to evaluate the outcomes of this program. Has important implications for designing activities for medical educators. They’re using not just the personal part, but the meso and the macro dynamics.

And using an established methodology in a new and underexplored context, which in this case is Vietnam, I think it’s something really important. And it has impact, as we’ve just pointed out, on theory as well as practice. So I think it can influence decision-making, not only in Vietnam, but otherwise.

Let’s move on to the voting. First of all, for methods one to five, we’ll go Jason, Lara, Jon.

Jason Frank: Jon had some good points about some head scratchers in the text. I don’t know if it’s just lost in translation or whatever. But overall, this is a really straightforward paper, in my opinion. I’m going to give it a four.

Lara Varpio: Same, same reasons. It’s a four.

Jonathan Sherbino: The conceptual framework doesn’t make sense to me. I’m giving it a two. Spicy.

Linda Snell: Ooh. That’s interesting. I’m giving it a four as well, reasons given.

Okay, how about impact or education usefulness?

Jason Frank: I’m going to give this a four again, and my rationale is anybody implementing anything, especially faculty development programs, can look at this paper for lessons for all of us about more effective implementation.

Lara Varpio: Agreed. I’m going to give it a four because I think the primary lesson here is that when it comes to looking at the success of an innovation, of an effort, don’t just assume you can, you know, did I meet my objectives? Are the students happy? That’s not enough information. That doesn’t help us because this paper shows us that that’s not really insightful. That doesn’t reflect what actually happened.

Jonathan Sherbino: I think the lessons for faculty development are already established. They don’t set out to actually do an analysis of this innovation as they try to articulate. The challenges of being a medical educator in Vietnam are concerning, but I’m also not 100% sure it represents their definition of what a medical educator is. And so I’m not sure what the usefulness is going to be for me. I’m going to give it a two. Oh.

Jason Frank: Boom.

Linda Snell: Well, I actually think it’s very useful. I agree with Lara, and surprisingly, I agree with Jason. So it gets a four from me.

Linda Snell: One final thing I’ll point out is that I picked this paper because… It was selected as the paper of the year from Teaching And Learning In Medicine. A panel of educators and authors and editors looked at a series of papers and said, this was the one that had the most impact, influence, was most accessible. So obviously, some of us anyway, Jonn.

Jason Frank: Are in good company.

Jonathan Sherbino: Obviously, I don’t know what I’m talking about is obviously what that means.

Linda Snell: Obviously, some of us may differ with this, Jon. So. If you want to reach us, go to paperspodcast.com or you can email us at thepaperspodcast at gmail. That said, thanks all for listening to this excellent paper of the year, even though some of us disagree. And we’ll see you all next time.

Lara Varpio: Talk to you later.

Jonathan Sherbino: For a side off, I have just a shout out to Aidan Nelson, who is an Associate Pediatrics Program Director in Weill Cornell in New York, New York. I’m tempted to do my New York, New York accent, but I don’t think I can.

Lara Varpio: No, don’t do it. Just don’t do it yet. No, no, no. That’s just going to be bad.

Jonathan Sherbino: Nate, Adin wrote us some really nice things. He says, I just listened to the recent podcast on the pedagogy of silence. And wanted to share something with you that one of my teachers taught me. While working as a counselor at a summer camp, Rabbi Mike Mellen taught me when you ask a group a question, you shut your mouth, wait, give them time to answer.

Jonathan Sherbino: If you get uncomfortable with the silence before they do, you’ll speak up and answer your own question before they have a chance, and you’ve turned your engaging interaction into a boarding lecture. So when I ask a group of trainees questions on rounds, I shut my mouth and start counting to 10. Somebody will start to say something, and a 10-second pause helps me b patient while giving me something to do while waiting for them. So thanks, Adin, for the kind words about the podcast. Thanks for the very helpful, practical teaching tip for the next time all of us are on rounds. Thanks for listening.

[music]

Take care, everybody.

Jason Frank: You’ve been listening to The Papers Podcast. We hope we made you just slightly smarter. The podcast is a production of the Unit For Teaching And Learning at the Karolinska Institute. The executive producer today was my friend, Teresa Sörö.

The technical producer today was Samuel Lundberg. You can learn more about the Papers Podcast and contact us at www.thepaperspodcast.com. Thank you for listening, everybody. And thank you for all you do. Take care.

Acknowledgment

This transcript was generated using machine transcription technology, followed by manual editing for accuracy and clarity. While we strive for precision, there may be minor discrepancies between the spoken content and the text. We appreciate your understanding and encourage you to refer to the original podcast for the most accurate context.