Exploring the role of classroom-based learning in professional identity formation of family practice residents using the experiences, trajectories, and reifications framework

Fostering the clinician as teacher: A realist review

BACKGROUND

Clinician-teachers, physicians with educational responsibilities in either classroom or clinical setting, are assumed to add value by virtue of their dual role. The clinical responsibilities are often prioritised over the educational tasks. How and under which circumstances clinician-teachers are able to perform their educational role and create added value for different stakeholders is currently unclear.

OBJECTIVES

To identify for whom, how and under which circumstances educational activities executed by CTs by virtue of their dual role add value to others.

SCOPE

CTs activities linking the system of education and clinical practice beyond direct patient interactions and purposefully executed.

METHODS

A realist review was conducted. Databases were searched in two stages: a narrow conventional search, followed by a comprehensive artificial intelligence-aided search. Studies concerning clinician-teachers' dual role were included. Realist analysis was applied to identify in which contexts resource mechanisms triggered reasoning mechanisms, which led to specific outcomes for different stakeholders.

RESULTS

Sixty-six studies were included. In contexts where clinician-teachers' dual role was formally recognised and valued, clinician-teachers benefitted from the credibility and legitimacy bestowed on them, making the transfer of domain-specific knowledge more impactful. In contexts where sociocultural differences between both systems existed, CTs were able to mediate and adjust recommendations aligned with stakeholders' perceived relevance. Also, contexts organised to support both roles made resource mechanisms more impactful. Clinician-teachers added value to students' clinical competency and learning environment, and to educational organisations' curricular innovation. In their clinical workspace, clinician-teachers added value by enhancing colleague physicians' teaching expertise, implementing educational innovations and recruiting students for scarce specialisms.

CONCLUSION

Clinician-teachers add value to students, colleague physicians and the clinical and educational contexts at large. Domain-specific knowledge of both systems was important to gain credibility and achieve added value. Openness, formal recognition and allocated time for both roles in educational and clinical contexts towards the dual role are important to strengthen the impact of the dual role.

A scoping review and theory-informed conceptual model of professional identity formation in medical education

INTRODUCTION

Professional identity formation (PIF) is a central tenet of effective medical education. However, efforts to support, assess and study PIF are hindered by unclear definitions and conceptualisations of what it means to 'think, act, and feel like a physician'. Gaps in understanding PIF, and by extension, its support mechanisms, can predispose individuals towards disengaged or unprofessional conduct and institutions towards short-sighted or reactionary responses to systemic issues.

METHODS

A Systematic Evidence-Based Approach-guided systematic scoping review of PIF theories was conducted related to medical students, trainees and practising doctors, published between 1 January 2000 and 31 December 2021 in PubMed, Embase, ERIC and Scopus databases.

RESULTS

A total of 2441 abstracts were reviewed, 607 full-text articles evaluated and 204 articles included. The domains identified were understanding PIF through the lens of pivotal theories and characterising PIF by delineating the underlying factors that influence it and processes that define it.

CONCLUSIONS

Based on regnant theories and frameworks related to self-concepts of identity and personhood, the relationships between key PIF influences, processes and outcomes were examined. A theory-backed integrated conceptual model was proposed to delineate the interconnected relationships among these, aiming to untangle some of the complexities inherent to PIF, to shed light on existing practices and to identify shortcomings in our understanding so as to develop mechanisms in support of its multifaceted, interlinked components.

'You are not alone.' An exploratory study on open-topic, guided collaborative reflection sessions during the General Practice placement

BACKGROUND

To support professional development of medical students faced with challenges of the clinical phase, collaborative reflection sessions (CRSs) are used to share and reflect on workplace experiences. Facilitation of CRSs seems essential to optimise learning and to provide important skills for lifelong learning as a professional. However, little is known about which workplace experiences students share in CRSs without advance guidance on specific topics, and how reflecting on these experiences contributes to students' professional development. Therefore, we explored which workplace experiences students shared, what they learned from reflection on these experiences, and how they perceived the value of CRSs.

METHODS

We conducted an exploratory study among medical students (N = 99) during their General Practice placement. Students were invited to openly share workplace experiences, without pre-imposed instruction. A thematic analysis was performed on shared experiences and student learning gains. Students' perceptions of CRSs were analysed using descriptive statistics.

RESULTS

All 99 students volunteered to fill out the questionnaire. We found four themes relating to students' shared experiences: interactions with patients, complex patient care, diagnostic or therapeutic considerations, and dealing with collegial issues. Regarding students' learning gains, we found 6 themes: learning from others or learning from sharing with others, learning about learning, communication skills, self-regulation, determination of position within the healthcare team, and importance of good documentation. Students indicated that they learned from reflection on their own and peer's workplace experiences. Students valued the CRSs as a safe environment in which to share workplace experiences and helpful for their professional development.

CONCLUSIONS

In the challenging General Practice placement, open-topic, guided CRSs provide a helpful and valued learning environment relevant to professional development and offer opportunities for vicarious learning among peers. CRSs may also be a valuable tool to incorporate into other placements.

Academic half days, noon conferences and classroom-based education in postgraduate medical education: a scoping review

BACKGROUND

Classroom-based education (CBE) is ubiquitous in postgraduate medical education (PGME), but to date no studies have synthesized the literature on the topic. We conducted a scoping review focusing on academic half days and noon conferences.

METHODS

We searched 4 databases (MEDLINE [OVID], Embase [OVID], ERIC [EBSCO] and Web of Science) from inception to December 2021, performed reference and citation harvesting, and applied predetermined inclusion and exclusion criteria to our screening. We used 2 frameworks for the analysis: "experiences, trajectories and reifications" and "description, justification and clarification."

RESULTS

We included 90 studies, of which 55 focused on resident experiences, 29 on trajectories and 6 on reification. We classified 44 studies as "description," 38 as "justification" and 8 as "clarification." In the description studies, 12 compared academic half days with noon conferences, 23 described specific teaching topics, and 9 focused on resources needed for CBE. Justification studies examined the effects of CBE on outcomes, such as examination scores (17) and use of teaching strategies in team-based learning, principles of adult learning and e-learning (15). Of the 8 clarification studies, topics included the role of CBE in PGME, stakeholder perspectives and transfer of knowledge between classroom and workplace.

INTERPRETATION

Much of the existing literature is either a description of various aspects of CBE or justification of particular teaching strategies. Few studies exist on how and why CBE works; future studies should aim to clarify how CBE facilitates resident learning within the sociocultural framework of PGME.

A Qualitative Study of Pediatric Residents' Experiences at Morning Report

Objectives

Morning Report is a prevalent classroom learning activity in residency programs. Yet, its contribution to resident education remains unclear. Our objective was to explore pediatric residents' perceptions of the purpose of Morning Report as well as their experiences at Morning Report both as learners and resident presenters.

Methods

We performed a qualitative study with a grounded theory approach using semi-structured focus groups of pediatric residents (November 2016-July 2017) from a large academic health center. We analyzed data with the constant comparative method, generating codes using an iterative approach and collecting data until reaching saturation. We identified major themes and resolved disagreements by consensus.

Results

Twenty-six residents participated in five focus groups. Data analysis yielded four themes: Morning Report is Multipurpose, Socialization and Engagement Influence the Learning Environment, Potential for Emotional Discomfort, and Barriers to Prioritizing Morning Report Attendance. Residents felt the primary purpose of Morning Report was acquiring medical knowledge, but also acknowledged Morning Report's added benefits of providing an opportunity for socialization and a mental reprieve before work rounds. Residents felt Morning Report was educational when engaged in interactive discussion; however, it was challenging to meet the differing needs in this mixed learner level format. Some resident learners were hesitant to participate due to fears of being judged, and some resident presenters perceived a need to be topic experts. Clinical responsibilities and exhaustion following busy service rotations often precluded Morning Report attendance.

Conclusion

Pediatric residents described numerous purposes of Morning Report, including opportunities for valuable learning. Self-perceived learning was positively influenced by engagement and a sense of connection and challenged by emotional discomfort at times. Future work can explore how to best promote engagement and foster a safe learning environment.

Classroom-Based Learning in an Academic Obstetrics and Gynecology Residency Training Program

Objectives

Classroom-based learning such as academic half days (AHDs) are complementary to workplace learning in postgraduate medical education. This study examined three research questions: the purpose of AHDs, elements of an effective AHD, and factors that make AHD sustainable.

Methods

We conducted a case study of the AHD in a large Obstetrics and Gynecology residency program at the University of British Columbia. Residents were interviewed in 2013 (n = 11) and 2018 (n = 7) and the program administrator was interviewed in 2018. The themes in each research question were identified by modified inductive analysis.

Results

Residents expressed that the purposes of AHD included: providing organization and an overview for their knowledge acquisition; preparation for their Royal College specialty exam; and to provide a venue for peer support and mentorship. Elements of an effective AHD include the repetition of key concepts; formative assessments such as quizzes, a suitable balance of faculty input and resident active participation, and protection from clinical duty during AHD. Regarding the sustainability of AHD, themes included: addressing barriers to faculty participation, providing administrative support for logistical needs, and providing feedback to faculty.

Conclusions

This work provides important insights into the purpose, effectiveness, and sustainability of AHDs for those who design and implement classroom learning for residents.

Residents’ Perception of the Educational Program “Family Medicine” in Kazakhstan: A Focus Group Study

Целью данного исследования было: восприятие обучения, мнение резидентов, обучающихся по программе «Семейная медицина», и определение потребности резидентов программы «Семейная медицина».   Методы . В этом качественном исследовании были проведены четыре полуторачасовых фокус-группы с 24 ординаторами, обучаемыми по программе резидентуры по семейной медицине Западно-Казахстанского университета, и результаты были проанализированы с использованием тематического анализа. Результаты. Анализ появления пяти тем и 14 вопросов подтем, которые были классифицированы по областям для обсуждения в фокус-группах: восприятие особенности ФМ, Мотивация доходов, Преимущества и внешний вид категории товаров, Жалобы и проблемы, пожелания по просмотру программ, идеальное значение имеют. Выводы. Это исследование выявления наличия жителей, которые ранее не учитывались в достаточной мере. Компетенции и содержание программы будут изменены в соответствии с назначением резидентов.

Effect of Residents-as-Teachers in Rural Community-Based Medical Education on the Learning of Medical Students and Residents: A Thematic Analysis

Residents-as-teachers (RaT) is a theoretical framework emphasizing the significance of the similar learning background of teachers and learners. In Japan, community-based medical education (CBME) is a practical approach to teaching family medicine. This study aimed to investigate the impact and challenges of RaT on the learning of medical students and residents in CBME at a rural community hospital in Japan. Over the course of a year, the researchers conducted one-on-one interviews with three residents and ten medical students participating in family medicine training at the hospital. The interviews were recorded and transcribed verbatim. Grounded theory was used in the data analysis to clarify the findings. Three key themes emerged from the research: lack of educational experience with RaT, effectiveness of RaT, and challenges of RaT. Although participants were prejudiced against RaT, they felt its implementation could facilitate the establishment of beneficial relationships between learners and teachers. They were also able to participate in medical teams effectively. The findings suggest that the increased participation of senior doctors in RaT could strengthen its learning effects. RaT in rural CBME should be applied in various contexts, and its effectiveness should be further investigated both qualitatively and quantitatively.

A participant perspective on collaborative reflection: video-stimulated interviews show what residents value and why

The potential of reflection for learning and development is broadly accepted across the medical curriculum. Our understanding of how exactly reflection yields its educational promise, however, is limited to broad hints at the relation between reflection and learning. Yet, such understanding is essential to the (re)design of reflection education for learning and development. In this qualitative study, we used participants' video-stimulated comments on actual practice to identify features that do or do not make collaborative reflection valuable to participants. In doing so, we focus on aspects of the interactional process that constitute the educational activity of reflection. To identify valuable and less valuable features of collaborative reflection, we conducted one-on-one video-stimulated interviews with Dutch general practice residents about collaborative reflection sessions in their training program. Residents were invited to comment on any aspect of the session that they did or did not value. We synthesized all positively and negatively valued features and associated explanations put forward in residents' narratives into shared normative orientations about collaborative reflection: what are the shared norms that residents display in telling about positive and negative experiences with collaborative reflection? These normative orientations display residents' views on the aim of collaborative reflection (educational value for all) and the norms that allegedly contribute to realizing this aim (inclusivity and diversity, safety, and efficiency). These norms are also reflected in specific educational activities that ostensibly contribute to educational value. As such, the current synthesis of normative orientations displayed in residents' narratives about valuable and less valuable elements of collaborative reflection deepen our understanding of reflection and its supposed connection with educational outcomes. Moreover, the current empirical endeavor illustrates the value of video-stimulated interviews as a tool to value features of educational processes for future educational enhancements.

Becoming a clinician: Trainee identity formation within the general practice supervisory relationship

OBJECTIVES

Becoming a clinician is a trajectory of identity formation in the context of supervised practice. This is a social process where the supervisory relationship is key. Therefore, to know how to support identity formation of clinical trainees, it is necessary to understand how this happens within the supervisory relationship. Our aim was to develop a conceptualisation of trainee identity formation within the general practice supervisory relationship to aid its support.

METHODS

We took a critical realist approach using case study design and 'cultural worlds' theory as a conceptual frame. Each case comprised a general practice trainee and supervisor pair. Our data were weekly audiorecordings of interactions between trainee, supervisor and a patient over 12 weeks augmented by post-interaction reflections and sequential interviews. We undertook interpretive analysis using dialogic methods focusing on the doing of language and the cultural discourses expressed.

RESULTS

We identified three social discourses centring on: clinical responsibility; ownership of clinical knowledge, and measures of trainee competency. Versions of these discourses defined four trainee-supervisor relational arrangements within which trainee and supervisor assumed reciprocal identities. We labelled these: junior learner and expert clinician; apprentice assistant and master coach, and lead clinician and advisor. We found a trajectory across these identity arrangements. Behind this trajectory was an invitation by the supervisor to the trainee into the social space of clinician and a readiness of the trainee to accept this invitation. Congruence in supervisor and trainee positioning was important.

CONCLUSIONS

In the supervisory relationship, trainee and supervisor adopted reciprocal identities. For trainees to progress to identity of 'lead clinician,' supervisors needed to invite their trainee into this space and vacate it themselves. Congruence between supervisor positioning of their trainee and trainee authorship of themselves was important and was aided by explicit dialogue and common purpose. We offer a model and language for trainees, supervisors and departments or schools to facilitate this.

What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine

PURPOSE

Research on professional identity formation has largely ignored how race, ethnicity, and the larger sociohistorical context work to shape medical students' professional identity. Researchers investigated how physician-trainees considered underrepresented in medicine (URM) negotiate their professional identity within the larger sociohistorical context that casts them in a negative light.

METHOD

In this qualitative study, 14 black/African American medical students were recruited from the Medical College of Georgia at Augusta University and Emory University College of Medicine between September 2018 and April 2019. Using constructive grounded theory and Swann's model of identity negotiation, the authors analyzed interview data for how students negotiate their racial and professional identities within medical education.

RESULTS

The results indicated that URM students were aware of the negative stereotypes ascribed to black individuals and the potential for the medical community to view them negatively. In response, students employed identity cues and strategies to bring the community's perceptions in line with how they perceived themselves-black and a physician. Specifically, students actively worked to integrate their racial and professional identities by "giving back" to the African American community. Community-initiated mentoring from non-URM physicians helped to reify students' hope that they could have a racialized professional identity.

CONCLUSIONS

Race, ethnicity, and the larger sociohistorical context is often overlooked in professional identity formation research, and this omission has resulted in an underappreciation of the challenges URM physicians' experience as they develop a professional identity. Within the context of this study, findings demonstrated that black/African American physicians negotiated the formation of professional identity within a challenging sociohistorical context, which should be given greater consideration in related research.

The informal curriculum of family medicine - what does it entail and how is it taught to residents? A systematic review

Background

The informal curriculum is a seemingly well-explored concept in the realm of medical education. However, it is a concept with multiple definitions and the term “the hidden curriculum” is often used interchangeably. In short, they both refer to the implicit learning taking place outside the formal curriculum, encompassing both a trickling down effect of organizational values and attitudes passed on by a mentor or colleague. While the informal curriculum is a recurrent theme in medical education literature; it is seldom discussed in Family Medicine. As the informal curriculum is likely to be highly influential in the forming of future family practitioners, our aim was to explore the area further, with respect to the following: which elements of the informal curriculum are applicable in a Family Medicine context and what educational interventions for Family Medicine residents, visualizing the various educational elements of it, have been performed?

Methods

We conducted a systematic review comprising iterative literature searches and a narrative synthesis of the results.

Results

Twenty articles, published between 2000 and 2019, were included in the analysis which resulted in three partly interrelated themes comprising the informal curriculum in Family Medicine: gaining cultural competence, achieving medical professionalism and dealing with uncertainty. The themes on cultural competence and uncertainty seemed to be more contextual than professionalism, the latter being discussed in relation to the informal curriculum across other medical disciplines as well. Formalized training for Family Medicine residents in aspects of the informal curriculum appeared to be lacking, and in general, the quality of the few interventional studies found was low.

Conclusions

Important aspects of being a family practitioner, such as cultural competence and dealing with uncertainty, are learned through a context-dependent informal curriculum. In order to ensure a more uniform base for all residents and to reduce the impact of the individual supervisor’s preferences, complementary formalized training would be beneficial. However, to date there are too few studies published to conclude how to best teach the informal curriculum.

Trial registration

The systematic review was registered with Prospero; registration number CRD42018104819.

A Review of Strategies for Enhancing Clarity and Reader Accessibility of Qualitative Research Results

Objective. To characterize elements of the results section of qualitative research reports that make findings more accessible to readers. Methods. Two analytical methods were used for this review. First, published reviews and textbooks written by experts outlining how to evaluate qualitative research were retrieved and reviewed to identify common elements that enhance clarity of the results section. In the second analysis, the authors analyzed the results sections of a subset of qualitative studies to identify, from a reader's point of view, aspects that enhanced and detracted from communication of the results. Findings. Four elements improve accessibility of the results section for readers of qualitative research reports. Content, the first element, describes what information the reader should look for in the results section. Style of results, the second element, identifies wording choices that improve reader accessibility and understanding. Narrative flow, the third element, describes a results section that flows smoothly and logically. Structural cohesiveness, the final element, outlines effective organization of the results section. Results. While authors take several approaches to the presentation of results in qualitative research reports, some strategies appear to be more common and effective than others. The efficient presentation of results can impact a reader's assessment of the quality and credibility of a study. Identified content and stylistic elements should be considered by authors hoping to make the results of their qualitative research more accessible and comprehensible to readers.

Dispositional Humility Of Clinicians In An Interprofessional Primary Care Environment: A Mixed Methods Study

Objectives

Dispositional humility in professionals is a character trait that allows one to monitor self-centered occupational drive and to pay attention to the needs of other professionals. The aim of this study is to test whether or not clinicians working in interprofessional team care environments identify the character trait of humility as an important factor for successful collaborative relationships. This study aimed to revise a concept map of dispositional humility created through literature review.

Design

An explanatory sequential mixed-methods study was composed of the HEXACO personality test and the Integrative Medicine Attitude Questionnaire, followed by summative and directed content analyses of one-on-one interview data in order to identify the element of dispositional humility.

Setting

In the State of Washington, USA, where physicians (MD/DO), nurse practitioners (NP) and naturopathic clinicians (ND) serve Medicaid patients in community clinics.

Participants

6 MDs, 4 NPs, and 11 NDs.

Results

Twenty-one primary care clinicians were enrolled. Fifteen clinicians completed the interview. It was observed that the: 1) honesty-humility trait (p<0.01), conscientiousness (&p<0.01), and openness to experience (p<0.05) domains of primary care clinicians were statistically significantly higher than the reference standards; 2) attitudes toward integrative medicine did not differentiate the different clinician types; and 3) qualitative data supported the component of dispositional humility as a desirable trait in professionals with whom they would like to work.

Conclusion

To maintain high-quality patient care while working as a team, limiting self-interest while focusing on the needs of others may be necessary and in the best interest of patients. An attitude of accepting the principles of integrative medicine has permeated this sample of primary healthcare workers. Both quantitative and qualitative analyses revealed that humility was viewed as an important character trait for successful interprofessional collaboration. A revised concept map of dispositional humility to enhance collaborative relationships was created.

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