Uncovering the ecology of clinical education: a dramaturgical study of informal learning in clinical teams

Online Self-Presentation by Traditional Chinese Medicine and Western Medicine Medical Professionals in China

Despite increasing research that examines language features of online medical consultation (OMC) conversations in China, limited attention has been directed to how medical professionals purposefully present themselves in their biographies on OMC websites, an emerging genre of health communication, with even fewer comparative studies on traditional Chinese medicine (TCM) and Western medicine (WM) medical professionals in this regard. To fill these gaps, this study compares the personal claims and self-presentational strategies used in TCM and WM medical professionals' biographies on a Chinese OMC website. It is found that while Chinese TCM and WM medical professionals present themselves in similar ways, they also demonstrate some important differences. The similarities may be driven by their shared goal of building trust in the OMC context, whereas the differences may be ascribed to TCM-WM differences in clinical philosophies, education histories, clinical cultures, and medical practices.

Second Victim Experiences of Health Care Learners and the Influence of the Training Environment on Postevent Adaptation

Objective

To investigate the experience of medical and graduate learners with second victim experience (SVE) after medical errors or adverse patient outcomes, including impact on training and identification of factors that shape their postevent recovery.

Patients and Methods

The validated Second Victim Experience and Support Tool-Revised (SVEST-R), Physician Well-Being Index, and supplemental open-ended questions were administered to multidisciplinary health care learners between April 8, 2022, and May 30, 2022, across a large academic health institution. Open-ended responses were qualitatively analyzed for iterative themes related to impact of SVE on the training experience.

Results

Of the 206 survey respondents, 144 answered at least 1 open-ended question, with 62.1% (n=91) reporting at least 1 SVE. Participants discussed a wide range of SVEs and indicated that their postevent response was influenced by their training environment. Lack of support from supervisors and staff exacerbated high stress situations. Some trainees felt blamed and unsupported after a traumatic experience. Others emphasized that positive training experiences and supportive supervisors helped them grow and regain confidence. Learners described postevent processing strategies helpful to their recovery. Some, however, felt disincentivized from seeking support.

Conclusion

This multidisciplinary study of learners found that the training environment was influential in postevent recovery. Our findings support the need for the inclusion of education on SVEs and adaptive coping mechanisms as part of health care professional educational curriculums. Educators and health care staff may benefit from enhanced education on best practices to support trainees after stressful or traumatic patient events.

Supervisory knowing in practice across medical specialities

Clinical supervisors play key roles in facilitating trainee learning. Yet combining that role with patient care complicates both roles. So, we need to know how both roles can effectively co-occur. When facilitating their trainees' learning through practice, supervisors draw on their skills - clinical and supervisory - and available opportunities in their practice. This process can be conceptualised as supervisory knowing in practice (or contextual knowing) and offers ways to elaborate on how facilitating trainees' learning can be optimised. The practice-based study presented and discussed here examined clinical supervisors' knowing in practice related to facilitating trainee learning, across three medical specialities. Nineteen clinical supervisors from emergency medicine, internal medicine and surgery, were interviewed about their roles and engagement with trainees. Interview transcripts were analysed in two stages. Firstly, a framework analysis, informed by interdependent learning theory was conducted, focussing on affordances and individual engagement. Secondly, drawing on practice theory, a further layer of analysis was undertaken interrogating supervisors' knowing in practice. We identified two common domains of supervisor practice used to facilitate trainee learning: (1) orientating and assessing trainees' readiness (or capabilities), (2) sequencing and enriching pedagogic practices. Yet across the speciality groups the supervisors' knowing in practice differed and were shaped by a trio of: (i) disciplinary practices, (ii) situational requirements and (iii) clinician preference. Overall, we offer a new reading of clinical supervision as practice differences generated distinct supervisory knowing in practice. These findings emphasise clinical supervision as fundamentally entwined in the speciality's practice; and reinforce alignments with patient care.

From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students

PURPOSE

Microaggressions targeting clinical learners cause harm and threaten learning. Clinical supervisors can be powerful allies by intervening when microaggressions occur. This study explored general and student-nominated skilled supervisors' perspectives on responding to microaggressions targeting clinical learners.

METHOD

This single-institution, qualitative study within a constructivist paradigm explored faculty supervisor experiences with bystander response to microaggressions targeting learners. Clinical supervisors in medicine and surgery departments and those across departments nominated by students as skilled microaggression responders were invited to discuss microaggression scenarios targeting students in semistructured focus groups in the U.S. in 2020-2021. Investigators applied the framework method of thematic analysis to identify themes.

RESULTS

Forty-two faculty (31 medicine and surgery ["general"], 11 "student-nominated" as skilled responders) joined 10 focus groups (6 "general," 3 "student-nominated," 1 mixed). Four themes characterized experiences responding to microaggressions targeting learners: bystander goals, noticing, acting, and continuous learning. Participants' response goals were protecting learners, safeguarding learning, and teaching microaggression response skills. Noticing was influenced by past experiences with microaggressions and acculturation to clinical environments. Bystander action stemmed from (1) microaggression type, (2) personal emotional vulnerability, (3) knowledge of student preferences for supervisor response, and (4) clinical and educational context. Bystander action was more common when participants regarded all microaggressions as harmful, understood student preferences for faculty response, expected to err (growth mindset), and framed microaggressions as opportunities for humble reflection, intellectual candor, and teaching. Microaggression response required continuous learning through informal and formal skills development.

CONCLUSIONS

Complex factors govern faculty bystander response to microaggressions targeting clinical learners. Efforts to strengthen faculty bystander response should incorporate skill-building around preemptive discussions with learners and using intellectual candor to promote psychological safety, learning, and bystander action. Additional investigation is needed on how to incorporate these skills into team workflows and to assess outcomes of specific response strategies.

Informal and Incidental Learning in the Clinical Learning Environment: Learning Through Complexity and Uncertainty During COVID-19

In the time of the COVID-19 pandemic, where clinical environments are plagued by both uncertainty and complexity, the importance of the informal and social aspects of learning among health care teams cannot be exaggerated. While there have been attempts to better understand the nuances of informal learning in the clinical environment through descriptions of the tacit or hidden curriculum, incidental learning in medical education has only been partially captured in the research. Understood through concepts borrowed from the Cynefin conceptual framework for sensemaking, the early stages of the pandemic immersed clinical teams in complex and chaotic situations where there was no immediately apparent relationship between cause and effect. Health care teams had to act quickly amidst the chaos: they had to first act, make sense of, and respond with intentionality. Informal and incidental learning (IIL) emerged as a byproduct of acting with the tools and knowledge available in the moment. To integrate the informal, sometimes haphazard nature of emergence among health care teams, educators require an understanding of IIL. This understanding can help medical educators prepare health professions learners for the cognitive dissonance that accompanies uncertainty in clinical practice. The authors introduce IIL as an explanatory framework to describe how teams navigate complexity in the clinical learning environment and to better inform curricular development for health professions training that prepares learners for uncertainty. While further research in IIL is needed to illuminate tacit knowledge that makes learning explicit for all audiences in the health professions, there are opportunities to cultivate learners' skills in formal curricula through various learning interventions to prime them for IIL when they enter complex clinical learning environments.

The social construction of teacher and learner identities in medicine and surgery

INTRODUCTION

There are growing concerns about the quality and consistency of postgraduate clinical education. In response, faculty development for clinical teachers has improved formal aspects such as the assessment of performance, but informal work-based teaching and learning have proved intractable. This problem has exposed a lack of research into how clinical teaching and learning are shaped by their cultural contexts. This paper explores the relationship between teacher-learner identity, educational practice and the workplace educational cultures of two major specialties: internal medicine and surgery.

METHODS

This was a secondary analysis of a large dataset, comprising field notes, participant interviews, images and video-recordings gathered in an ethnographic study. The lead author embedded himself in four clinical teams (two surgical and two medical) in two different hospitals. The authors undertook a critical reanalysis of the observational dataset, using Dialogism and Figured Worlds theory to identify how teachers and postgraduate learners figured and authored their professional identities in the specialty-specific cultural worlds of surgery and internal medicine.

RESULTS

Surgery and internal medicine privileged different ways of being, knowing and talking in formal and informal settings, where trainees authored themselves as capable practitioners. The discourse of surgical education constructed proximal coaching relationships in which trainees placed themselves at reputational risk in a closely observed, embodied practice. Internal medicine constructed more distal educational relationships, in which trainees negotiated abstract representations of patients' presentations, which aligned to a greater or lesser degree with supervisors' representations.

CONCLUSIONS

Our research suggests that clinical education and the identity positions available to teachers and learners were strongly influenced by the cultural worlds of individual specialties. Attempts to change work-based learning should be founded on situated knowledge of specialty-specific clinical workplace cultures and should be done in collaboration with the people who work there, the clinicians.

Strategies for sharing pedagogical knowledge in clinical education in adapting to the impact of COVID-19

BACKGROUND

The extent and complexity of knowledge in the field of medicine necessitate modern education systems. Rational performance in the education system depends on the synergy of educators through knowledge sharing as the basis of education. The aim of this study was to investigate the knowledge-sharing strategies in clinical education and its changes during the COVID-19 pandemic.

MATERIALS AND METHODS

The content analysis was conducted in 2019 at Birjand University of Medical Sciences. Twenty-seven clinical instructors with enough experience and knowledge in the field of clinical education were chosen based on purposive theoretical sampling. Data collection was done by semi-structured interviews, which continued until data saturation. The interviews were recorded, transcribed, and read several times to obtain a whole understanding. Next, the meaning units and initial codes were identified, and then, they were classified into subcategories and categories. To ensure the trustworthiness of the data, Lincoln and Guba criteria were considered.

RESULTS

The results of the study include five pedagogical knowledge-sharing strategies: "peer-helping, clinical education workplace," "use of cyberspace," "student mediation," "working teams," and "scientific communities." Coronavirus pandemic was identified as the "facilitator" and the "culturalization factor" of knowledge sharing. In addition, "lack of shared knowledge management," "lack of compliance with needs," and "dispersion of content" were considered as barriers to the efficiency of pedagogical knowledge sharing during the coronavirus pandemic.

CONCLUSIONS

Sharing knowledge in a clinical education setting could continue by various strategies. The results can be used in planning for the professional development of professors.

Thinking about social power and hierarchy in medical education

CONTEXT

Social power has been diversely conceptualised in many academic areas. Operating on both the micro (interactional) and macro (structural) levels, we understand power to shape behaviour and knowledge through both repression and production. Hierarchies are one organising form of power, stratifying individuals or groups based on the possession of valued social resources.

DISCUSSION

Medicine is a highly organised social context where work and learning are contingent on interaction and thereby influenced greatly by social power and hierarchy. Despite the relevance of power to education research, there are many unrealized opportunities to use this construct to expand our understanding of how physicians work and learn. Hierarchy, when considered in our field, is typically gestured to as an omnipresent feature of the clinical environment that harms low-status individuals by repressing their ability to communicate openly and exercise their agency. This may be true in many circumstances, but this conceptualization of hierarchy neglects consideration of other aspects of hierarchy that may be generative for understanding the experiences of medical learners. For example, medical learners may experience the superimposition of multiple hierarchies, some of which are fluid and some of which are calcified, some of which are productive and helpful and some of which are oppressive and harmful. Power may work 'up' and 'across' hierarchical ranks, rather than just from higher status to lower status individuals.

CONCLUSION

The conceptualizations of how social power shapes human behaviour are diverse. Often paired with hierarchy, or social arrangement, these social scientific ideas have much to offer our collective study of the ways that health professionals learn and practice. Accordingly, we posit that a consideration of the ways social power works through hierarchies to nurture or harm the growth of learners should be granted explicit consideration in the framing and conduct of medical education research.