"Learning the Lingo": A Grounded Theory Study of Telephone Talk in Clinical Education

Unravelling underlying processes in intraprofessional workplace learning in residency

BACKGROUND

To deliver high-quality collaborative care, residents need to be trained across the boundaries of their medical specialty (intraprofessional learning). The current literature does not provide insights into the underlying processes that influence intraprofessional learning. The aim of this study was to gain insight into the processes that occur during intraprofessional workplace learning in residency training, by exploring everyday intraprofessional interactions experienced by residents, with the ultimate objective of improving collaborative practice.

METHOD

We conducted a focused ethnography using field observations and in-depth interviews with residents at an academic children's hospital in the Netherlands. In 2022, nine residents from four different medical specialties were shadowed and/or interviewed. In total, >120 hours of observation and 10 interviews were conducted. Data collection and analysis were conducted iteratively and discussed in a research team with diverse perspectives, as well as with a sounding board group of stakeholders.

RESULTS

Residents were involved in numerous intraprofessional interactions as part of their daily work. We identified three themes that shed light on the underlying processes that occur during intraprofessional workplace learning: (1) residents' agency, (2) ingroups and outgroups and (3) communication about intraprofessional collaboration.

CONCLUSIONS

Collaborative practice offers many intraprofessional learning opportunities but does not automatically result in learning from, with and about other specialties to improve intraprofessional collaborative care. Overarching the identified themes, we emphasise the pivotal role of the resident-supervisor dyad in facilitating residents' engagement in the learning opportunities of complex intraprofessional care. Furthermore, we propose that promoting deliberate practice and shared responsibility in collaborative care are crucial to better prepare residents for their roles and responsibilities in delivering high-quality collaborative patient care.

How do residents respond to uncertainty with peers and supervisors in multidisciplinary teams? Insights from simulations with epistemic fidelity

BACKGROUND

Residents struggle to express clinical uncertainty, often exhibiting negative cognitive, behavioral, and emotional responses to uncertainty when engaging with patients or supervisors. However, the Integrative Model of Uncertainty Tolerance posits that individuals may have positive or negative responses to perceived uncertainty. Situational characteristics, such as interactions with other health professionals, can impact whether the response is positive or negative. The team context in which residents interact with resident peers and supervisors could represent varying situational characteristics that enable a spectrum of responses to uncertainty. Understanding the situational characteristics of multidisciplinary teams that allow residents to display positive responses to perceived uncertainty could inform strategies to foster positive responses to uncertainty in other contexts. We explored resident responses to perceived uncertainty in a simulated multidisciplinary team context.

METHODS

A simulation-primed qualitative inquiry approach was used. Fourteen residents from Cardiology and Obstetrics and Gynecology participated in simulation scenarios involving pregnant patients with heart disease. We incorporated epistemic fidelity through the deliberate inclusion of ambiguity and complexity to prompt uncertainty. Audio recordings of debriefing sessions were analyzed using directed content analysis.

RESULTS

Residents recognized that uncertainty is unavoidable, and positive responses to uncertainty are crucial to team dynamics and patient safety. While residents had positive responses to expressing uncertainty to peers, they had predominantly negative responses to expressing uncertainty to supervisors. Predominant negative response to supervisors related to judgement from supervisors, and impacts on perceived trustworthiness or independence. Although residents recognized expressing uncertainty to a supervisor could identify opportunities for learning and resolve their uncertainty, the negative responses overshadowed the positive responses. Residents highly valued instances in which supervisors were forthcoming about their own uncertainty.

CONCLUSIONS

Through participation in simulations with epistemic fidelity, residents reflected on how they perceive and respond to uncertainty in multidisciplinary teams. Our findings emphasize the role of situational characteristics, particularly peers and supervisors, in moderating responses to perceived uncertainty. The productive discussions around responses to uncertainty in debriefing sessions suggest further studies of multidisciplinary simulations could enhance our understanding of how uncertainty is expressed, and potentially be used as an instructional intervention to promote positive responses to uncertainty.

Call the on-Call: Authentic Team Training on an Interprofessional Training Ward - A Case Study

Purpose

There is a disconnect between how healthcare teams commonly are trained and how they act in reality. The purpose with this paper was to present a learning activity that prepares healthcare students to authentic teamwork where team members are fluent and move between different localities, and to explore how this setting affects learning.

Methods

A learning activity "Call the On-Call" consisting of two elements, workplace team training where team members are separated into different locations, and a telephone communication exercise, was created. A case study approach using mixed methods was adopted to explore medical-, nurse-, physiotherapy- and occupational therapy students and supervisor perspectives of the effects of the learning activity. Data collection involved surveys, notes from reflection sessions, a focus group interview, and field observations. Thematic analysis was applied for qualitative data and descriptive statistics for quantitative data. The sociocultural learning theory, social capital theory, was used to conceptualize and analyse the findings.

Results

The majority of the students (n=198) perceived that the learning activity developed their interprofessional and professional competence, but to a varying degree. Especially nursing students found value in the learning activity, above all due to increased confidence in calling a doctor. Physio- and occupational therapy students lacked the opportunity to be active during the telephone exercise, however, they described how it increased their interprofessional competence. Authenticity was highlighted as the key strength of the learning activity from all professions. Concerns that team building would suffer as a result of splitting the student team proved unfounded.

Conclusion

The learning activity created new opportunities for students to reflect on interprofessional collaboration. Constant physical proximity during training is not essential for effective healthcare team building. Splitting the student team during training may in fact enhance interprofessional learning and lead to progression in interprofessional communication.

Scratching beneath the surface: How organisational culture influences curricular reform

INTRODUCTION

Curricular reform is often proposed as the means to improve medical education and training. However, reform itself may not lead to noticeable change, possibly because the influence of organisational culture on change is given insufficient attention. We used a national reform of early-years surgical training as a natural opportunity to examine the interplay between organisational culture and change in surgical education. Our specific research question was: in what ways did organisational culture influence the implementation of Improving Surgical Training (IST)?

METHODS

This is a qualitative study underpinned by social constructivism. Interviews were conducted with core surgical trainees (n = 46) and their supervising consultants (n = 25) across Scotland in 2020-2021. Data coding and analysis were initially inductive. The themes indicated the importance of many cultural factors as barriers or enablers to IST implementation. We therefore carried out a deductive, secondary data analysis using Johnson's (1988) cultural web model to identify and examine the different elements of organisational culture and their impact on IST.

RESULTS

The cultural web enabled a detailed understanding of how organisational culture influenced IST implementation as per Johnson's six elements-Rituals and Routines (e.g. departmental rotas), Stories (e.g. historical training norms and culture), Symbols (e.g. feedback mechanisms, visibility and value placed on education), Power Structures (e.g. who has the power in local contexts), Organisational Structures (e.g. relationships and accountability) and the Control System (e.g. consultant job plans and service targets)-and how these interact. However, it did not shed light on the influence of exogenous events on change.

CONCLUSION

Our data reveal cultural reasons why this curricular reform met with varying degrees of success across different hospital sites, reinforcing that curricular reform is not simply about putting recommendations into practice. Many different aspects of context must be considered when planning and evaluating change in medical education and training.

'Us versus them': A social identity perspective of internal medicine trainees

INTRODUCTION

Silos and group boundaries in the clinical workplace can result in interprofessional conflict which can be a source of anxiety for doctors in training. The social identity perspective (SIP) incorporates theories of social identity and self-categorisation, and may provide a useful lens to understand the socialisation and identity development of doctors. This study aimed to determine if and how the SIP may provide insight into intergroup relations as experienced by internal medicine (IM) trainees in Scotland.

METHODS

Interprofessional communication workshops hosted as part of an IM boot camp between August 2020 and March 2021 were audio recorded and transcribed verbatim. Subsequent individual interviews with consenting trainees further explored social identity and intergroup relations. Data analysis employed template analysis and deductive independent coding with the SIP informing the initial coding template and new codes added inductively.

RESULTS

Seventeen workshops, involving 100 trainees, and ten subsequent individual interviews were included. Trainees related to the social identity of an IM doctor and to stereotypes within the workplace. They described intergroup tensions resulting from a perception of differing priorities. They experienced outgroup derogation and the impact of role modelling those in their social group during their identity development.

DISCUSSION

The SIP provides a useful lens to understand the social phenomena at play for IM trainees. It confirms the expectation of conflict between specialties and negative perceptions of outgroups. There is a need to consider the hidden curriculum of socialisation in the workplace during training and the influence of the learning environment on identity development.

Representation, interaction and interpretation. Making sense of the context in clinical reasoning

BACKGROUND

All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised.

AIMS

Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning.

DISCUSSION

We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning.

CONCLUSION

The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.

Fifteen simulated patient working formats to use in communication skills training: Report of a survey

OBJECTIVE

Simulated and standardized patients (SPs) are increasingly being used in communication skills training for healthcare professionals' education. Despite this broad use of SPs, there is no recent literature with an overview on SP working formats being used. We ran a study to fill this gap.

METHODS

First, a survey on formats on the use of SPs in various curricula for education of healthcare professionals in Belgium and The Netherlands was run by members of the Dutch Association of Medical Education Special Interest Group on Simulated and Standardized patients (SIG-NL/B). Then the SIG-NL/B organized a national workshop where professionals working with or interested in SPs were invited to come forward with SP working formats they used. They were also asked to provide relevant details about the use. Finally, the outcomes of these two phases were combined.

RESULTS

Fifteen SP working formats were found. Six of them were described before. The details of all formats are listed and discussed.

CONCLUSION

We categorised 15 SP working formats. The choice to use a particular format is mainly based on the learning objectives of the session involved and the expertise at hand.

Qualitative Research in Veterinary Medical Education: Part 1-Principles of Qualitative Design

Qualitative methodologies are relative newcomers to health sciences education research. While they may look very different to their quantitative counterparts in terms of size and scope, when well-applied they offer a fresh perspective and generate valuable research findings. Although qualitative research is being increasingly conducted in veterinary medical education, there are few contextualized resources to assist those who would like to develop their expertise in this area. In this article, we address this by introducing the principles of qualitative research design in a veterinary medical education context. Drawing from a range of contemporary resources, we explore the types of research goals and questions that are amenable to qualitative inquiry and discuss the process of formulating a worthwhile research question. We explain what research paradigms are and introduce readers to some of the methodological options available to them in qualitative research. Examples from veterinary medical education are used to illustrate key points. In a second companion article, we will focus on the decisions that need to be made regarding data sampling, collection, and analysis. We will also consider how qualitative research is evaluated, and discuss how qualitative findings are applied. Taken together, the two articles build an understanding of qualitative research, illuminate its potential to contribute to the scholarship of teaching and learning in veterinary medical education, and equip readers with an improved capacity to appraise its value.

Intraprofessional workplace learning in postgraduate medical education: a scoping review

BACKGROUND

Residents need to be trained across the boundaries of their own specialty to prepare them for collaborative practice. Intraprofessional learning (i.e. between individuals of different disciplines within the same profession) has received little attention in the postgraduate medical education literature, in contrast to the extensive literature on interprofessional learning between individuals of different professions. To address this gap, we performed a scoping review to investigate what and how residents learn from workplace-related intraprofessional activities, and what factors influence learning.

METHODS

The PRISMA guidelines were used to conduct a scoping review of empirical studies on intraprofessional workplace learning in postgraduate medical education published between 1 January 2000 to 16 April 2020 in Pubmed, Embase, PsycINFO, ERIC and Web of Science. This study applied 'best fit' framework-based synthesis to map the existing evidence, using the presage-process-product (3P) model developed by Tynjälä (2013).

RESULTS

Four thousand three hundred thirty records were screened, and 37 articles were included. This review identified influencing (presage) factors that derived from the sociocultural environment, learner and learning context. Studies described that complexity of care can both facilitate and hinder learning. Furthermore, intraprofessional learning is threatened by professional stereotyping and negative perceptions, and awareness of learning opportunities and explicit reflection are critical in intraprofessional workplace learning. Studies described a range of informal and formal intraprofessional activities (process) under the headings of collaboration in clinical practice, rotations or placements, formal educational sessions and simulated workplace training. In general, learners responded well and their attitudes and perceptions improved, learners reported increased knowledge and skills and positive behavioural changes (product). Learning outcomes were reported in the domains of patient-centred care, collaborative attitudes and respect, mutual knowledge and understanding, collaborative decision making, communication, leadership, teamwork and reflexivity.

CONCLUSIONS

This review gives insight into the high learning potential of intraprofessional activities. Many of the included studies relied on self-reported perceptions of change, therefore, future research should focus on generating more robust evidence including objectively examined outcome measures. This review offers a comprehensive overview of the factors that influence intraprofessional workplace learning in postgraduate medical education. Finally, we provide recommendations for enhancing intraprofessional learning in clinical practice.

An act of performance: Exploring residents' decision-making processes to seek help

CONTEXT

Residents are expected to ask for help when feeling insufficiently confident or competent to act in patients' best interests. While previous studies focused on the perspective of supervisor-resident relationships in residents' help-seeking decisions, attention for how the workplace environment and, more specifically, other health care team members influence these decisions is limited. Using a sociocultural lens, this study aimed to explore how residents' decision-making processes to seek help are shaped by their workplace environment.

METHODS

Through a constructivist grounded theory methodology, we purposively and theoretically sampled 18 residents: 9 juniors (postgraduate year 1/2) and 9 seniors (postgraduate year 5/6) at Amsterdam University Medical Centers. Using semi-structured interviews, participating residents' decision-making processes to seek help during patient care delivery were explored. Data collection and analysis were iterative; themes were identified using constant comparative analysis.

RESULTS

Residents described their help-seeking decision-making processes as an 'act of performance': they considered how asking for help could potentially impact their assessments. They described this act of performance as the product of an internal 'balancing act' with at its core the non-negotiable priority for providing safe and high-quality patient care. With this in mind, residents weighed up demonstrating the ability to work independently, maintaining credibility and becoming an accepted member of the health care team when deciding to seek help. This 'balancing act' was influenced by sociocultural characteristics of the learning environment, residents' relationships with supervisors and the perceived approachability of other health care team members.

CONCLUSIONS

This study suggests that sociocultural forces influence residents to experience help-seeking as an act of performance. Especially, a safe learning environment resulting from constructive relationships with supervisors and the approachability of other health care team members lowered the barriers to seek help. Supervisors could address these barriers by having regular conversations with residents about when to seek help.

The Keyword Effect: A Grounded Theory Study Exploring the Role of Keywords in Clinical Communication

OBJECTIVES

Keywords, also known as "buzzwords" or "trigger words," serve as memorable descriptors to associate physical findings with specific diagnoses. These terms, such as "target lesion" and "steeple sign," liken a physical or radiographic finding to a nonmedical comparator as a means to elicit an associated diagnosis. Keywords permeate medical literature and clinical conversations. However, the potential for miscommunicating critical information exists and the impact of keywords on communication-related medical error is unknown. We explored the use of keywords and how physicians perceive their use in their clinical communication as part of patient care.

METHODS

With a grounded theory approach, semistructured interviews were completed in 2016 to 2017 with a purposive sample of 15 resident and attending physicians working in one pediatric emergency department, where clinical conversations occur frequently between providers of different specialties and levels of training. Constant comparative analysis for emergent themes was conducted. We identified key themes and examined their relationships to theorize how keywords affect clinical communication.

RESULTS

We identified three major aspects: 1) keywords belong to the culture of medicine, by which providers connect with each other using specialized terms that imply a shared experience and knowledge base. This culture encourages keyword use. 2) By encapsulating a pattern of clinical findings into one word or short phrases, keywords allow for convenient, efficient communication of both diagnoses and of thought processes between providers. 3) Keywords, however, may mislead; if incorrectly applied to a given clinical situation, they may be misinterpreted by the receiver, or they may introduce bias to diagnostic decision making.

CONCLUSIONS

More than simple descriptors, keywords can communicate entire diagnoses and activate illness scripts between providers. Also, keywords are integral to the culture and language of medicine. However, providers should be aware of the potential negative effects of keywords in clinical conversations and must balance the demands of efficient and accurate communication with the potential for miscommunication and error.

'Too male, too pale, too stale': a qualitative exploration of student experiences of gender bias within medical education

OBJECTIVE

To explore medical student perceptions and experiences of gender bias within medical education.

SETTING

Gender bias-'prejudiced actions or thoughts based on the perception that women are not equal to men'-is a widespread issue. Within medicine, the pay gap, under-representation of women in senior roles and sexual harassment are among the most concerning issues demonstrating its presence and impact. While research investigating experiences of clinicians is gaining traction, investigation of medical students' experiences is lacking. This qualitative study analyses medical students' experiences of gender bias within their education to discern any patterns to this bias. Illuminating the current state of medical education gender bias will hopefully highlight areas in which student experience could be improved. Constructivist thematic analysis was used to analyse data, informed by William's patterns of gender bias, intersectional feminism and communities of practice theory.

PARTICIPANTS

Thirty-two medical students from multiple UK medical schools participated in individual interviews. Nine faculty members were also interviewed to triangulate data.

RESULTS

Gender bias has an overt presence during medical student education, manifesting in line with William's patterns of bias, impacting career aspirations. Physical environments serve to manifest organisational values, sending implicit messages regarding who is most welcome-currently, this imagery remains 'too male, too pale…too stale'. Existing gender initiatives require careful scrutiny, as this work identifies the superficial application of positive action, and a failure to affect meaningful change.

CONCLUSIONS

Despite progress having been made regarding overt gender discrimination, implicit bias persists, with existing positive action inadequate in promoting the advancement of women. Institutions should mandate participation in implicit bias education programmes for all staff and must strive to revise the imagery within physical environments to better represent society. Gender initiatives, like Athena Scientific Women's Academic Network, also require large-scale evaluation regarding their impact, which this work found to be lacking.

Readiness to prescribe: Using educational design to untie the Gordian Knot

Introduction

Junior residents routinely prescribe medications for hospitalised patients with only arms-length supervision, which compromises patient safety. A cardinal example is insulin prescribing, which is commonplace, routinely delegated to very junior doctors, difficult, potentially very dangerous, and getting no better. Our aim was to operationalise the concept of ‘readiness to prescribe’ by validating an instrument to quality-improve residents’ workplace prescribing education.

Methods

Guided by theories of behaviour change, implementation, and error, and by empirical evidence, we developed and refined a mixed-methods 24-item evaluation instrument, and analysed numerical responses from Foundation Trainees (junior residents) in Northern Ireland, UK using principal axis factoring, and conducted a framework analysis of participants’ free-text responses.

Results

255 trainees participated, 54% women and 46% men, 80% of whom were in the second foundation year. The analysis converged on a 4-factor solution explaining 57% of the variance. Participants rated their capability to prescribe higher (79%) than their capability to learn to prescribe (69%; p<0.001) and rated the support to their prescribing education lower still (43%; p<0.001). The findings were similar in men and women, first and second year trainees, and in different hospitals. Free text responses described an unreflective type of learning from experience in which participants tended to 'get by' when faced with complex problems.

Discussion

Operationalising readiness to prescribe as a duality, comprising residents’ capability and the fitness of their educational environments, demonstrated room for improvement in both. We offer the instrument to help clinical educators improve the two in tandem.