'HARD' Training Environments Foster a Distinct Sense of Place: A Scoping Review and a Conceptual Framework on 'Place' and Clinical Reasoning Development.

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.