TY - JOUR
T1 - 'HARD' training environments foster a distinct sense of place
T2 - a scoping review and a conceptual framework on 'Place' and clinical reasoning development
AU - Dharmaratne, Sisira
AU - Jayarathne, Wasana
AU - Olupeliyawa, Asela
AU - Wong, Kam Cheong
AU - Tobin, Stephen
AU - Limberger, Damien
AU - Osuagwu, Uchechukwu Levi
PY - 2026/2/1
Y1 - 2026/2/1
N2 - INTRODUCTION: Understanding the unique affordances of place-based medical education (PBME) is essential to train highly skilled physicians for a particular place. Clinical reasoning (CR)-a context-specific core physician competency-is well suited to achieve this goal. OBJECTIVE: To map existing evidence and conceptualise how 'place' impacts CR development in medical students and trainees. DESIGN: Using PRISMA ScR guidelines, empirical, peer-reviewed, full-text, English-language journal articles on PBME in Medline, CINAHL, Scopus, and ERIC databases published between 1975 and 2024 were reviewed. Place and CR development were defined as participants' sense of authentic clinical training environment and learning of relevant to cognitive and sociocultural processes of patient diagnosis and management, respectively. A theory informed constructivist content analysis of data was undertaken. RESULTS: Of 2874 records, 27 met the inclusion criteria. CR development was an indirect finding in 26/27 reports. Evidence was available only for rural medically underserved places which afforded 'HARD', detailed as follows: longitudinal integrated clerkships, routine parallel consultations, closely knit teams, and workforce constraints enabled Hands-on patient engagements (H), Abundant patient exposures (A), and supported taking responsibility in patient care (R). Exposure to diverse practice niches and resource constraints sensitised students to Diversity in clinical practices (D). DISCUSSION: 'HARD' characterises place dependence and place attachment in CR development and fosters an identity aligning with expert clinicians situating reasoning in context. These underpin dynamic patterns of context signifying the distinctiveness of place. CONCLUSIONS: Exploring distinctiveness of place using 'HARD' framework can transform PBME scholarship to prepare more physicians ready to serve intended places, including the medically underserved.
AB - INTRODUCTION: Understanding the unique affordances of place-based medical education (PBME) is essential to train highly skilled physicians for a particular place. Clinical reasoning (CR)-a context-specific core physician competency-is well suited to achieve this goal. OBJECTIVE: To map existing evidence and conceptualise how 'place' impacts CR development in medical students and trainees. DESIGN: Using PRISMA ScR guidelines, empirical, peer-reviewed, full-text, English-language journal articles on PBME in Medline, CINAHL, Scopus, and ERIC databases published between 1975 and 2024 were reviewed. Place and CR development were defined as participants' sense of authentic clinical training environment and learning of relevant to cognitive and sociocultural processes of patient diagnosis and management, respectively. A theory informed constructivist content analysis of data was undertaken. RESULTS: Of 2874 records, 27 met the inclusion criteria. CR development was an indirect finding in 26/27 reports. Evidence was available only for rural medically underserved places which afforded 'HARD', detailed as follows: longitudinal integrated clerkships, routine parallel consultations, closely knit teams, and workforce constraints enabled Hands-on patient engagements (H), Abundant patient exposures (A), and supported taking responsibility in patient care (R). Exposure to diverse practice niches and resource constraints sensitised students to Diversity in clinical practices (D). DISCUSSION: 'HARD' characterises place dependence and place attachment in CR development and fosters an identity aligning with expert clinicians situating reasoning in context. These underpin dynamic patterns of context signifying the distinctiveness of place. CONCLUSIONS: Exploring distinctiveness of place using 'HARD' framework can transform PBME scholarship to prepare more physicians ready to serve intended places, including the medically underserved.
KW - experience‐based learning
KW - health workforce
KW - medically underserved communities
KW - place‐based medical education
KW - rural clinical school
KW - workplace‐based learning
UR - http://www.scopus.com/inward/record.url?scp=105027131332&partnerID=8YFLogxK
UR - https://go.openathens.net/redirector/westernsydney.edu.au?url=https://doi.org/10.1111/ajr.70145
U2 - 10.1111/ajr.70145
DO - 10.1111/ajr.70145
M3 - Article
C2 - 41527414
AN - SCOPUS:105027131332
SN - 1038-5282
VL - 34
JO - Australian Journal of Rural Health
JF - Australian Journal of Rural Health
IS - 1
M1 - e70145
ER -