Struggling to be self-directed: residents' paradoxical beliefs about learning

Metacognition in oral health education: A pedagogy worthy of further exploration

AIM

This study aimed to investigate the perceptions of dental students and teachers about introducing metacognition pedagogy within an established clinical professional curriculum to provide primary data informing its feasibility.

METHODOLOGY AND METHOD

A qualitative study using phenomenography methodology was undertaken as part of a master's dissertation. Semi-structured interviews were conducted on 16 participants which included 9 clinical teachers and 7 dental students.

FINDINGS

Metacognition pedagogy was positively perceived by most of the participants as being beneficial to students' learning in oral health education. A few reported some negativity. All participants identified some challenges to be addressed if a metacognition pedagogy was to be implemented in the undergraduate curriculum.

CONCLUSION

According to the perceptions of most participants in the study, metacognition emerged as a potential factor in improving student learning and exam performance, and facilitating the development of critical thinking, professionalism, and clinical skills. In the context of rigorous, demanding, and challenging courses, and recognising the complexities and uncertainties inherent in health professional working environments, metacognition emerges as a valuable tool, fostering self-awareness, regulation, and adaptability. Ultimately, metacognition has the capability to shape more adept learners and clinicians, yielding benefits for students, teachers, and patients alike.

Learning strategies for the advanced trainee in specialist training

BACKGROUND

A significant factor of clinicians' learning is based on their ability to effectively transfer acquired knowledge, skills, and attitudes from specialty-specific clinical courses to their working environment.

MATERIAL AND METHOD

We conducted semi-structured interviews with 20 anaesthesiologist trainees (i.e. residents) in four group and five individual interviews using SRL principles as sensitizing concepts. Data were collected and analyzed iteratively using thematic analysis.

RESULTS

Advanced trainees are highly motivated to explore what they have learned in specialty-specific courses, but they often face several barriers in implementing their learning in the workplace environment. Four themes emerged from the interview data: 'Be ready to learn', "Take the 'take-home-messages' home', "Be ready to create your own opportunities', and "Face it, it's not entirely up to you'. Understanding the challenges regarding transferring knowledge from courses to the working environment is an important lesson for assisting trainees set their learning goals, monitor their progress, and re-evaluate their SRL processes.

CONCLUSION

Even for advanced trainees, successfully transferring knowledge from specialty-specific courses often requires adequate commitment and support. Medical supervisors and other relevant stakeholders must be aware of their shared responsibility for creating individual environments that support opportunities for trainees to self-regulate their learning.

Making goals count: A theory-informed approach to on-shift learning goals

Supervisors often ask emergency medicine trainees for their learning goals at the start of a clinical shift, though they may do so without considering the reasons for this practice. Recognizing the underlying rationale for voicing on-shift learning goals and proactively considering solutions for some of the associated challenges can help learners and supervisors employ this practice to its full potential. Goal articulation is rooted in educational principles such as self-regulated learning, targeted performance feedback, and collaborative relationships between learner and supervisor. Despite the potential for on-shift learning goals to augment learning, there are numerous barriers that make it challenging for learners and supervisors alike to create or follow up on meaningful goals. Learner-related challenges include uncertainty about how to develop goals within an unpredictable clinical environment and creating goals too narrow or broad in scope. Supervisor-related challenges include difficulties integrating direct observation into the clinical workflow and a desire to avoid negative feedback. The learning environment also presents inherent challenges, such as lack of longitudinal supervisor-learner relationships, time constraints, space limitations, and incentives for learners to conceal their knowledge gaps. The authors discuss these challenges to effective on-shift learning goals and propose solutions that target the learner's approach, the supervisor's approach, and the learning environment itself.

Curriculum development in Liberia's first postgraduate psychiatry training programme

This paper describes the implementation of curricula for Liberia's first-ever psychiatry training programme in 2019 and the actions of the only two Liberian psychiatrists in the country at the time in developing and executing a first-year postgraduate psychiatry training programme (i.e. residency) with support from international collaborators. It explores cultural differences in training models among collaborators and strategies to synergise them best. It highlights the assessment of trainees' (residents') basic knowledge on entry into the programme and how it guided immediate and short-term priority teaching objectives, including integrated training in neuroscience and neurology. The paper describes the strengths and challenges of this approach as well as opportunities for continued growth.

A patient follow-up intervention to improve medical decision making at an internal medicine residency program

OBJECTIVES

Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH).

METHODS

Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices.

RESULTS

Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies.

CONCLUSIONS

Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.

Exploring perspectives of personal learning plans in a residency programme

BACKGROUND

Personal learning plans (PLPs) have gained traction in postgraduate medical education as an avenue for enhancing resident learning. However, implementing PLPs in real-world education settings presents unique challenges. To realise the potential of PLPs, we must understand the factors that influence the quality of PLP implementation. The purpose of this study was to explore the use and implementation of PLPs during residency training from the residents' and academic advisors' perspectives within a competency-based residency programme.

METHODS

We conducted semi-structured interviews with residents (n = 18) and academic advisors (n = 9) in an Internal Medicine residency programme at a Canadian academic centre. Interviews were audio recorded, transcribed verbatim and analysed using open coding.

FINDINGS

Three higher order themes were developed to represent the participants' perceptions of implementing PLPs in a competency-based residency programme: (a) setting the stage for learning, (b) fostering meaningful engagement and (c) learning through reflection. Results indicated that implementing PLPs requires collaboration between residents and academic advisors and supports from the broader programme and institution. PLP implementation is an iterative process that can provide a salient avenue for reflection and the development of self-regulation skills.

DISCUSSION AND CONCLUSION

PLPs can be a useful tool to foster self-regulated learning skills in residency education. It is imperative to consider how social and environmental supports can be enacted to facilitate engagement with, and implementation of, PLPs.

Improved Patient Outcomes and Pediatric Resident Performance With a Parent and Faculty Communication Coaching Curriculum

Communication skills are an important part of patient care, but an often neglected part of residency training. Longitudinal active coaching of communication has the potential to effectively improve communication curricula. A novel communication coach curriculum was implemented with approximately half of a pediatric residency class. Residents were coached by both a parent and faculty coach on multiple occasions throughout their intern year. Effectiveness was evaluated through self-assessment, direct observation, chart review, and follow-up phone calls with families. This longitudinal communication coach curriculum was well-received and resulted in increased self-awareness of communication skills. Coachable behaviors improved in intervention residents, and their patients spoke more positively of their experiences with communication. Additionally, these patients were less likely to be readmitted than patients cared for by control residents. A longitudinal communication coaching model is a feasible and effective curriculum for pediatric residents.

Finding the right combination for self-directed learning: A focus group study of residents' choice and use of digital resources to support their learning

BACKGROUND

There has been a shift in postgraduate medical education towards digital educational resources-podcasts, videos, social media and other formats consumed asynchronously and apart from formal curricula. It is unclear what drives residents to select and use these resources. Understanding how and why residents choose digital resources can aid programme directors, faculty and residents in optimising residents' informal learning time.

METHOD

This focus group study was conducted with residents at two US internal medicine residency programmes. The authors used the framework approach to content analysis using self-determination theory as guide for deductive coding and iteratively assessing connections among codes and identifying themes. Trustworthiness was addressed through use of analytic memos, reflexive practice and member checking.

RESULTS

The authors conducted eight virtual focus groups (n = 23) from 5/27/20 to 6/11/20. Residents described that a feeling of 'should know' drove initial choices towards self-directed learning outside of work. Regular use of a resource was influenced by how the resource fit into a resident's lifestyle, the personal cognitive energy and the perceived 'activation energy' of using a particular resource. Familiarity, increased confidence and in-person social networks gained from digital resources served to reinforce and further guide resource choice.

CONCLUSIONS

The selection of digital resources for self-directed learning is driven by multiple factors, suggesting an interdependent relationship between the learning environment and a residents' cognitive capacity. Understanding these interconnections can help residents and clinical educators explicitly choose resources that fit their lifestyle and learning needs.

Scaffolding Self-Regulated Learning in Operative Dentistry Through Self-Assessment Training

OBJECTIVES

This study aimed to investigate how effective self-assessment training is in improving the self-regulated learning (SRL) ability of operative dentistry students. The secondary aim was to explore students' attitudes towards self-assessment in clinical settings.

INTRODUCTION

Self-assessment has been the focus of dental education research for decades and has been claimed to be cornerstone in the SRL process.

METHODS

This is quasi-experimental study conducted at Damascus University Faculty of Dental Medicine, Syria. A modified direct observation of procedural skills (DOPS) assessment protocol with a self-assessment component was applied to a convenience sample of students across five clinical encounters in 2022. Data were collected during clinical training on the DOPS form and at the end of the experiment using a structured questionnaire with a single open-ended question. The qualitative part of the study followed a deductive theory-informed content analysis approach, relying on Zimmerman SRL theory.

RESULTS

A total number of 32 students participated in the study, eight of whom were male. During the experiment assessment, participants showed overwhelming positive attitudes towards the utility of self-assessment (m ≥ 3.5; max:4) and the overall assessment method (3.3 ≥ m ≥ 3.5; max:4). Cronbach's alpha for the post-experiment questionnaire was 0.888. A total of 84.4% of the participants strongly agreed that self-assessment is useful in clinical training. Data collected (qualitative and quantitative) from participants revealed the positive effects of self-assessment on all three phases of SRL, especially the reflection phase.

CONCLUSION

Self-assessment practice and training showed positive results in terms of improving SRL and performance in a clinical context; SRL appeared to be affected by self-assessment in all phases (forethought, performance, and reflection). Participants' perceptions of self-assessment were generally very positive. These findings imply the potential benefits of applying self-assessment training interventions to foster the SRL ability of learners within the clinical context.

Barriers and enablers to achieving clinical procedure competency-based outcomes in a national paediatric training/residency program-a multi-centered qualitative study

BACKGROUND

In 2018, the Royal College of Physicians of Ireland revised its paediatric training program to a competency-based medical education (CBME) training/residency curriculum. This included a requirement to achieve competence in a number of core procedural skills to progress within the program. Internationally, simulation-based medical education (SBME) is gaining interest as an effective teaching pedagogy for training procedural skill competency. The objectives of this study were to (1) identify enablers and barriers for paediatric trainees to achieve their required procedural competencies, (2) gain insight on the feasibility of achieving the required procedural skills, and (3) explore what simulation-based resources are used as well as their role in achieving the required procedural skill competencies.

METHODS

A multi-centered qualitative study using semi-structured interviews was performed. Twenty-four paediatric consultants and trainees were recruited from two academic tertiary hospitals using purposive and snowball sampling. Interviews were conducted between March and September 2021, audio recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Three main themes regarding enablers for achieving procedural competencies were reported and include having protected training time, routine assessments, and a standardized curriculum. Barriers to achieving procedural competencies focused mainly on limited clinical exposure. The use of SBME was recommended by all participants (n = 24, 100%) to assist in achieving procedural competencies and most (n = 15, 62.5%) reported it is feasible to attain the required procedural skills in the paediatric CBME program.

CONCLUSION

It is feasible to achieve the required procedural competencies for most paediatric trainees, but this can be improved with protected training time, routine assessments, and a standardized curriculum. Barriers to achieving these skills mainly center on limited clinical exposure, which can be remedied by SBME. Further research is warranted to determine the costs and types of SBME tools available as well as teaching pedagogies to support paediatric trainees achieve their required procedural competencies.

Dermatology residents as educators: a qualitative study of identity formation

BACKGROUND

One of the many identities a physician comes to form during their career is their identity as an educator. Exploring formation of this identity may enrich our understanding of how physicians make decisions related to their roles as educators, their behaviors, and how this ultimately influences the educational environment. It is the aim of this study to investigate educator identity formation of dermatology residents while early in their careers.

METHODS

Drawing on a social constructionist paradigm, we conducted a qualitative study, utilizing an interpretative approach. We examined longitudinal data over a 12-month period using dermatology residents' written reflections from their professional portfolios and semi-structured interviews. We collected this data as we progressed through and beyond a 4-month professional development program designed to encourage residents' growth as educators. Sixty residents in their second, third, or final year of residency programs located in Riyadh, Saudi Arabia were invited to take part in this study. Twenty residents participated with sixty written reflections and 20 semi-structured interviews. Qualitative data were analyzed using a thematic analysis approach.

RESULTS

Sixty written reflections and 20 semi-structured interviews were analyzed. Data was categorized according to themes corresponding to the original research questions. For the first research question regarding identity formation, themes included definitions of education, the process of education, and identity development. For the second research question, 1 theme entitled professional development program included, the following sub-themes: individual act, interpersonal activity, and an organizational undertaking, with many believing that residency programs should prepare residents for their educator roles. Participants also described newfound leadership ambitions of creating new dermatology fellowship programs as a result of taking part in the Resident-as-Educator program.

CONCLUSIONS

Our study provides insights on the dynamic formation of educator identities amongst dermatology residents. Investment in developing residents as educators through professional development programs may instigate transformational change on the individual physician level and profession's level.

Utilizing a Quality Improvement Strategy to Increase Faculty Engagement With Resident Learning Goals

BACKGROUND

Establishing and achieving learning goals (LGs) are important lifelong learning skills for residents. Faculty are critical in facilitation and achievement of residents' LGs, yet many have difficulty with this role in the busy inpatient setting.

OBJECTIVES

Our primary aim was to improve faculty engagement in resident LGs, targeting ≥80% of faculty achieving a mean score ≥goal, over a period of 1 year by setting prerotation expectations and stressing team-based faculty accountability during the rotation in the current inpatient learning environment.

METHODS

We identified key barriers to addressing LGs on an inpatient subspecialty service. Key interventions included 1) introducing LGs to faculty, 2) establishing a communication/handover process among faculty, 3) LGs development, and 4) tracking accountability. Baseline mean faculty milestone scores were determined from the prior year. Over 1 year, we developed and refined a system for residents to create and document LGs with faculty oversight and review. We reviewed faculty evaluations quarterly to measure progress and reviewed rotation evaluations.

RESULTS

Faculty engagement with LGs improved through the course of the academic year. All but one faculty member had improved LGs scores during the intervention year. Most residents were very satisfied with the intervention and gave unprompted favorable feedback on rotation evaluations. The majority of submitted LGs were either partially or completely addressed.

CONCLUSIONS

We demonstrated that a quality improvement approach to a faculty educational skill is feasible and effective. Our intervention related to LGs may be modified for any medical learner in any inpatient or outpatient setting.

The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning

PURPOSE

Adaptive expertise (AE) has been identified as a critical trait to cultivate in future physicians. The 4-phase master adaptive learner (MAL) conceptual model describes the learning skills and behaviors necessary to develop AE. Though prior work has elucidated skills and behaviors used by MALs in the initial planning phase of learning, most resident learners are not thought to be MALs. In this study, the authors investigated how these majority "typical" learners develop AE by exploring the strategies they used in the planning phase of learning.

METHOD

Participants were resident physicians at graduate medical education (GME) training programs located at 4 academic medical centers in the United States. Participants participated in semistructured individual interviews in 2021, and interview transcripts were analyzed using constant comparative analysis of grounded theory.

RESULTS

Fourteen subjects representing 8 specialties were interviewed, generating 152 pages of transcripts for analysis. Three themes were identified: "Typical" learners were challenged by the transition from structured undergraduate medical education learning to less-structured GME learning, lacked necessary skills to easily navigate this transition, and relied on trial and error to develop their learning skills.

CONCLUSIONS

Participants used trial and error to find learning strategies to help them manage the systemic challenges encountered when transitioning from medical school to residency. The success (or failure) of these efforts was tied to learners' efficacy with the self-regulated learning concepts of agency, metacognitive goal setting, and motivation. A conceptual model is provided to describe the impact of these factors on residents' ability to be adaptive learners, and actionable recommendations are provided to help educators' efforts to foster adaptive learning skills and behaviors. These findings also provided valuable evidence of validity of the MAL model that has thus far been lacking.

How to Keep Training-After Residency Training

Lifelong learning in medicine is an important skill and ethical obligation, but many residents do not feel prepared to be effective self-directed learners when training ends. The learning sciences offer evidence to guide self-directed learning, but these insights have not been integrated into a practical and actionable plan for residents to improve their clinical knowledge and reasoning. We encourage residents to establish a self-directed learning plan, just as an athlete employs a training plan in the pursuit of excellence. We highlight four evidence-based learning principles (spaced practice, mixed practice, retrieval practice, and feedback) and four training strategies comprising a weekly training plan: case tracking, simulated cases, quizzing, and new evidence integration. We provide tips for residents to implement and refine their approach and discuss how residency programs can foster these routines and habits. By optimizing their scarce self-directed learning time with a training plan, residents may enhance patient care and their career satisfaction through their pursuit of clinical mastery.

Creating a better learning environment: a qualitative study uncovering the experiences of Master Adaptive Learners in residency

BACKGROUND

Adaptive expertise is an important physician skill, and the Master Adaptive Learner (MAL) conceptual model describes learner skills and behaviors integral to the acquisition of adaptive expertise. The learning environment is postulated to significantly impact how MALs learn, but it is unclear how these successful learners experience and interact with it. This study sought to understand the authentic experience of MALs within the learning environment and translate those experiences into practical recommendations to improve the learning environment for all trainees.

METHODS

Following a constructivist paradigm, we conducted a thematic analysis of transcripts from focus groups composed of MALs to identify commonalities in experiences and practices of successful postgraduate trainees in the learning environment. Saturation was achieved after seven focus groups, consisting of thirty-eight participants representing fourteen specialties from four institutions. Researchers coded transcripts using constant comparison analysis, which served as the foundation for our thematic analysis.

RESULTS

We identified eight themes and situated them within a 4-component model of the learning environment. Four themes were identified within the personal component: (1) patients drive learning; (2) learning has no endpoint; (3) management of emotions is crucial for learning; (4) successful learning requires a structured approach. Two themes were identified in the social component: (5) positive social relationships are leveraged to maximize learning; (6) teaching facilitates personal learning. Two themes were identified in the organizational component: (7) transitions challenge learners to adapt; (8) the learning environment dictates goal setting strategy. No major themes were identified in the physical/virtual component, although participants frequently used technology when learning.

CONCLUSIONS

Master Adaptive Learners experience similar facilitators of, and barriers to, success in the learning environment. Overall, our data show that acquisition of many successful strategies and skills that support learning are relegated to the hidden curriculum of residency training. Educators could support a more effective learning environment for all trainees by: (1) highlighting patients as the focal point of learning, (2) building a professional 'learner' identity, (3) teaching learning skills, and (4) creating opportunities for collaborative learning.

A Mixed-Methods Exploration of the Developmental Trajectory of Autonomous Motivation in Graduate Medical Learners

INTRODUCTION

Self-determination theory (SDT), when applied to curricular construction, emphasizes curiosity, self-awareness, and resilience. Physicians need these qualities to face the challenges of clinical practice. SDT offers a lens for medical educators to track learner development toward sustainable, rewarding careers. This study describes the changes observed in learner communications about feelings of competence, relatedness, and autonomy across a 3-year family medicine training program designed to develop activated, lifelong learners.

METHODS

This retrospective, mixed-methods case study uses a phenomenological approach to explore how 51 learners described their experiences at various intervals in residency training. Data collected from 2009 to 2015 from resident focus groups, competency assessment meetings, and faculty assessment reports inform a 3-stage analysis process to determine learner motivation levels along the SDT continuum.

RESULTS

Aggregated qualitative and quantitative data show residents' progression from introjection (controlled motivation) in PGY1, to identification (autonomous motivation) in PGY2, and integration (autonomous) by the end of PGY3. The examination of a single learner's data set reveals an advanced motivation level in PGY1 (identification), followed by a period of retrograde in PGY2 (introjection), then rebounding in PGY3 (identification), which illustrates how motivation level can be affected by external competency requirements and challenges related to career transitions.

DISCUSSION

The examination of self-motivation in medical learners has implications for curriculum development, assessment, teaching and self-directed learning, and resilience training. Learner awareness of intrinsic motivation, and the curriculum designed around it, can better prepare residents for challenges during residency and help them flourish in twenty-first-century medicine.

Can general surgery interns accurately measure their own technical skills? Analysis of cognitive bias in surgical residents' self-assessments

BACKGROUND

Accurate self-assessment of knowledge and technical skills is key to self-directed education required in surgical training. We aimed to investigate the presence and magnitude of cognitive bias in self-assessment among a cohort of surgical interns.

METHODS

First-year general surgery residents self-assessed performance on a battery of technical skill tasks (knot tying, suturing, vascular anastomosis, Fundamentals of Laparoscopic Skills peg transfer and intracorporeal suturing) at the beginning of residency. Each self-assessment was compared to actual performance. Bias and deviation were defined as arithmetic and absolute difference between actual and estimated scores. Spearman correlation assessed covariation between actual and estimated scores. Improvement in participant performance was analyzed after an end-of-year assessment.

RESULTS

Participants (N = 34) completed assessments from 2017 to 2019. Actual and self-assessment scores were positively correlated (0.55, P < .001). Residents generally underestimated performance (bias -4.7 + 8.1). Participants who performed above cohort average tended to assess themselves more negatively (bias -7.3 vs -2.3) and had a larger discrepancy between self and actual scores than below average performers (deviation index 9.7 + 8.2 vs 3.8 + 3.1, P < .05). End-of-year total scores improved in 31 (91.2%) participants by an average of 11 points (90 possible). Least accurate residents in initial self-assessments (deviation indices >75th percentile) improved less than more accurate residents (median 5 vs 16 points, P < .05). All residents with a deviation index >75 percentile underestimated their performance.

CONCLUSION

Cognitive bias in technical surgical skills is apparent in first-year surgical residents, particularly in those who are higher performers. Inaccuracy in self-assessment may influence improvement and should be addressed in surgical training.

Characteristics and quality of rotation-specific resident learning goals: a prospective study

Background: Residents are expected to develop the skills to set learning goals. Setting learning goals is part of self-regulated learning, setting the foundation for creating a learning plan, deploying learning strategies, and assessing their progress to those goals. While effective goal setting is essential to resident self-regulated learning, residents struggle with setting learning goals and desire faculty assistance with goal setting.Objective: We aimed to characterize the topics and quality of residents' rotation-specific learning goals.Design: We conducted a prospective study of 153 internal medicine residents, assessing 455 learning goals for general medicine inpatient rotations. We coded learning goal themes, competencies, and learning domains, and assessed quality using the validated Learning Goal Scoring Rubric. We compared topic categories, competencies, learning domains, and quality between the first and second months of postgraduate (PGY)-1 residents and between PGY-1 and PGY-3 residents. We assessed factors associated with learning goal completion.Results: The overall response rate was 80%. The top three learning goal categories were patient management, specific diseases related to general medicine, and teaching skills. There were no changes in learning goal characteristics between PGY-1 months (p ≥ 0.04). There were differences between PGY-1 and PGY-3 residents' learning goals in patient management (28% vs 6%; p < .001), specific disease conditions (19% vs 3%; p < .001), and teaching skills (2% vs 56%; p < .001). There was no difference in learning goal quality between PGY-1 months (1.63 vs. 1.67; p = 0.82). The PGY-3 learning goals were of higher quality than PGY-1 learning goals for the 'specific goal' item (1.38 vs. 0.98, p = 0.005), but not for other items or overall (all p ≥ 0.02). Residents reported 85% (297/347) learning goal completion.Conclusions: Resident rotation-specific learning goals reflect a broad array of topics. Residents' learning goal quality was low and residents may benefit from guidance to support residents' learning goals.

How is self-regulated learning documented in e-portfolios of trainees? A content analysis

BACKGROUND

It is assumed that portfolios contribute to self-regulated learning (SRL). Presence of these SRL processes within the documentation kept in portfolios is presupposed in common educational practices, such as the assessment of reflective entries. However, questions can be asked considering the presence of SRL within portfolios. The aim of this study was to gain insight into the documentation of SRL processes within the electronic (e)-portfolio content of medical trainees. SRL consists of numerous processes, for this study the focus was on self-assessment via reflection and feedback, goal-setting and planning, and monitoring, as these are the processes that health professions education research mentions to be supported by portfolios.

METHODS

A database containing 1022 anonymous e-portfolios from General Practitioner trainees was used to provide descriptive statistics of the various available e-portfolio forms. This was followed by a quantitative content analysis of 90 e-portfolios, for which, a codebook was constructed to rate the documentation of the included SRL processes.

RESULTS

The numbers of forms in the e-portfolios varied to a great extent. Content analysis showed a limited documentation of reflective entries, and available entries mainly described events and experiences without explanations and context. Feedback was generally limited to comments on what went well and lacked specificity, context and suggestions for future action. Learning goals and plans were short of specificity, but did contain challenging topics and different goals were compatible with each other. 75% of the e-portfolios showed (limited) signs of monitoring.

CONCLUSIONS

The e-portfolio content showed limited documentation of SRL processes. As documentation of SRL requires time and asks for a high level of introspection and writing skills, one cannot expect documentation of SRL processes to appear in e-portfolio content without efforts.

Professionals' perspectives on factors affecting GP trainees' patient mix: results from an interview and focus group study among professionals working in Dutch general practice

INTRODUCTION

Seeing and treating patients in daily practice forms the basis of general practitioner (GP) training. However, the types of patients seen by GP trainees do not always match trainees' educational needs. Knowledge about factors that shape the mix of patient types is limited, especially with regard to the role of the professionals who work in the GP practice.

AIM

We investigated factors affecting the mix of patients seen by GP trainees from the perspective of professionals.

DESIGN AND SETTING

This qualitative study involved GP trainees, GP supervisors, medical receptionists and nurse practitioners affiliated with a GP Specialty Training Institute in the Netherlands.

METHODS

Twelve focus groups and seven interviews with 73 participants were held. Data collection and analysis were iterative, using thematic analysis with a constant comparison methodology.

RESULTS

The characteristics of patients' health problems and the bond between the doctor and patient are important determinants of GP trainees' patient mix. Because trainees have not yet developed bonds with patients, they are less likely to see patients with complex health problems. However, trainees can deliberately influence their patient mix by paying purposeful attention to bonding with patients and by gaining professional trust through focused engagement with their colleagues.

CONCLUSION

Trainees' patient mix is affected by various factors. Trainees and team members can take steps to ensure that this mix matches trainees' educational needs, but their success depends on the interaction between trainees' behaviour, the attitudes of team members and the context. The findings show how the mix of patients seen by trainees can be influenced to become more trainee centred and learning oriented.

Flipping the classroom: a national pilot curriculum for physiology in neonatal-perinatal medicine

OBJECTIVE

To explore interest, feasibility, perceived effectiveness, and acceptability of a standardized, national physiology curriculum for neonatal-perinatal medicine (NPM) fellows using online videos for knowledge acquisition paired with flipped classrooms (FCs) for knowledge application.

STUDY DESIGN

Two educational programs pairing online videos with FCs were developed and peer-reviewed. These programs were piloted at five institutions. Fellows completed surveys, and fellows and educators participated in focus groups after their FC experiences.

RESULTS

Thirty-five fellows responded to the survey. Forty-one fellows and six educators participated in focus groups. Fellows and educators preferred online videos paired with FCs over didactic teaching and perceived them to be effective for knowledge acquisition and application.

CONCLUSION

Fellows and educators preferred FC learning over traditional didactics and reported that FCs facilitated creation of a learning community, fostering active learning. The favorable response toward this pilot project and the feasibility of its use supports further development of a standardized NPM physiology curriculum for fellowship training.

Self-regulated learning in the clinical context: a systematic review

OBJECTIVES

Research has suggested beneficial effects of self-regulated learning (SRL) for medical students' and residents' workplace-based learning. Ideally, learners go through a cyclic process of setting learning goals, choosing learning strategies and assessing progress towards goals. A clear overview of medical students' and residents' successful key strategies, influential factors and effective interventions to stimulate SRL in the workplace is missing. This systematic review aims to provide an overview of and a theoretical base for effective SRL strategies of medical students and residents for their learning in the clinical context.

METHODS

This systematic review was conducted according to the guidelines of the Association for Medical Education in Europe. We systematically searched PubMed, EMBASE, Web of Science, PsycINFO, ERIC and the Cochrane Library from January 1992 to July 2016. Qualitative and quantitative studies were included. Two reviewers independently performed the review process and assessed the methodological quality of included studies. A total of 3341 publications were initially identified and 18 were included in the review.

RESULTS

We found diversity in the use of SRL strategies by medical students and residents, which is linked to individual (goal setting), contextual (time pressure, patient care and supervision) and social (supervisors and peers) factors. Three types of intervention were identified (coaching, learning plans and supportive tools). However, all interventions focused on goal setting and monitoring and none on supporting self-evaluation.

CONCLUSIONS

Self-regulated learning in the clinical environment is a complex process that results from an interaction between person and context. Future research should focus on unravelling the process of SRL in the clinical context and specifically on how medical students and residents assess their progress towards goals.

Encouraging residents' professional development and career planning: the role of a development-oriented performance assessment

BACKGROUND

Current postgraduate medical training programmes fall short regarding residents' development of generic competencies (communication, collaboration, leadership, professionalism) and reflective and deliberate practice. Paying attention to these non-technical skills in a structural manner during postgraduate training could result in a workforce better prepared for practice. A development-oriented performance assessment (PA), which assists residents with assessment of performance and deliberately planned learning activities, could potentially contribute to filling this gap. This study aims to explore residents experiences with the PA.

METHODS

We conducted a qualitative interview study with 16 residents from four different medical specialties who participated in the PA, scheduled halfway postgraduate training. The PA was conducted by an external facilitator, a psychologist, and focused specifically on professional development and career planning. Residents were interviewed 6 months after the PA. Data were analysed using the framework method for qualitative analysis.

RESULTS

Residents found the PA to be of additional value for their training. The overarching merit was the opportunity to evaluate competencies not usually addressed in workplace-based assessments and progress conversations. In addition, the PA proved a valuable tool for assisting residents with reflecting upon their work and formulating their learning objectives and activities. Residents reported increased awareness of capacity, self-confidence and enhanced feelings of career-ownership. An important factor contributing to these outcomes was the relationship of trust with the facilitator and programme director.

CONCLUSION

The PA is a promising tool in fostering the development of generic competencies and reflective and deliberate practice. The participating residents, facilitator and programme directors were able to contribute to a safe learning environment away from the busy workplace. The facilitator plays an important role by providing credible and informative feedback. Commitment of the programme director is important for the implementation of developmental plans and learning activities.

Improving student midwives' workplace learning by moving from self- to co-regulated learning!

BACKGROUND

Contemporary perspectives on regulated learning are moving beyond models, emphasising individual learning (self-regulated learning) to models that position social transactions at the core of learning (co-regulated learning). In discussing this paradigm shift, it is important to study self- and co-regulated learning in situational context but research in the context of midwifery education is scarce.

OBJECTIVE

This study aimed to improve our understanding of regulating midwifery students' learning by exploring factors that promote or inhibit the capacity to independently self-regulate learning during internships.

DESIGN

We conducted a qualitative study involving semi-structured group discussions with final year undergraduate midwifery students (Belgium). Focus groups were audio-taped, transcribed verbatim and analysed in a thematic way.

FINDINGS

The majority of respondents did not experience an education intended to stimulate continuous self-regulated learning. They identified many social transactions (with mentors, teachers, teams of midwives, students, peer students, personal environments, personal coaches and curriculum managers) that were instrumental in promoting or inhibiting the ability to independently self-regulate. Flexibility and resilience to cope with the differences in practices, guidance, beliefs and behaviours of individual midwives within and between workplaces, was seen as paramount.

CONCLUSION

Broadening the perspective of the individual learner to the complex interplay between all the stakeholders involved with workplace learning is an essential step to move forward in the effort to improve student midwives' learning in the workplace.

Being a surgeon or doing surgery? A qualitative study of learning in the operating room

CONTEXT

A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery.

METHODS

Using a multi-site ethnographic and practice-based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students' participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices.

RESULTS

By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training.

CONCLUSIONS

The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high-quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery.

Coaching Residents in the Ambulatory Setting: Faculty Direct Observation and Resident Reflection

BACKGROUND

Direct observation can be valuable for learners' skill development in graduate medical education, but it is done infrequently. Information on how to optimize trainee learning from, and best practices of, direct observation interventions in the ambulatory setting is limited.

OBJECTIVE

We explored the impact of a focused outpatient direct observation and coaching intervention on internal medicine residents.

METHODS

Using a behavior checklist based on tenets of clinical excellence, 2 faculty preceptors observed outpatient primary care visits with 96% (46 of 48) of the internal medicine residents in 2017. Residents self-assessed their performance after the visit using the same checklist. Next, a focused coaching feedback session, emphasizing reflection, was structured to highlight areas of discrepancy between resident self-assessment and coach observation (blind spots), and residents were asked to identify goals for practice improvement.

RESULTS

Common blind spots in resident self-assessment related to collaborating with patients while using the electronic health record (48%, 21 of 44), hand washing (43%, 20 of 46), and asking thoughtful questions (40%, 18 of 45). At 1-month follow-up, 93% (43 of 46) of responding residents reported change in practice toward goals often or sometimes. All residents reported that the intervention felt comfortable, and 98% (45 of 46) noted that it helped them identify new behaviors to incorporate into clinical practice.

CONCLUSIONS

Structured episodes of direct observation and coaching in the outpatient setting, with a behavior checklist, appear acceptable and useful for internal medicine residents' learning and development.

Simple Frameworks for Daily Work: Innovative Strategies to Coach Residents Struggling With Time Management, Organization, and Efficiency

BACKGROUND

Organization and efficiency are central to success on busy inpatient services and may be relevant to demonstrating certain milestones. Most residents adopt these skills by observing supervisors and peers. For some, this method of emulation and adaptation does not occur, with the potential for a negative effect on patient care and team morale. Information on effective strategies for remediating organization and efficiency deficits is lacking.

OBJECTIVE

We explored the major themes of organization and efficiency referred to the University of Pennsylvania Department of Medicine Early Intervention and Remediation Committee (EIRC), and developed tools for their remediation.

METHODS

Assessments of residents and fellows referred to the EIRC between July 2014 and October 2016 were reviewed for organization and efficiency deficits. Common areas were identified, and an iterative process of learner observations and expert input was used to develop remediation tools.

RESULTS

Over a 2-year period, the EIRC developed remediation plans for 4% of residents (13 of 342 total residents), and for 1 internal medicine subspecialty fellow. Organization and efficiency was the primary or secondary deficit in more than half of those assessed. Most common deficiencies involved admitting a patient efficiently, performing effective prerounding, and composing daily progress notes/presentations. Remediation tools that provided deconstruction of tasks to their most granular and reproducible components were effective in improving performance.

CONCLUSIONS

Deficits in organization and efficiency can disproportionately affect resident performance and delay milestone achievement. Many residents would benefit from detailed frameworks and assistance with new approaches to basic elements of daily work.

Faculty Support for Self-Directed Learning in Internal Medicine Residency: A Qualitative Study Using Grounded Theory

PURPOSE

Self-directed learning (SDL) is part of residency training, which residents desire guidance in implementing. To characterize SDL within the clinical context, this study explored residents' perceptions of faculty members' role in promoting and supporting resident SDL.

METHOD

Using a constructivist grounded theory approach, the authors conducted seven focus groups with 46 internal medicine residents at the Mayo Clinic Internal Medicine Residency Program from October 2014 to January 2015. Focus group transcripts were deidentified and processed through open coding and analytic memo writing. Guided by a previously developed SDL model, data were analyzed regarding faculty member involvement in resident SDL. Themes were organized and patterns were discussed at team meetings, with constant comparison with new data. Trustworthiness was established using two member-check sessions.

RESULTS

The authors identified themes within the categories of faculty guidance for SDL, SDL versus other-directed learning (ODL), and faculty archetypes for supporting SDL. Clinical teachers play a key role in facilitating resident SDL and can provide guidance at each step in the SDL process. Residents discussed the distinction between SDL and ODL, highlighting the integrated nature of learning and interplay between the two approaches to learning. Residents identified themes relating to three archetypal approaches faculty implement to support resident SDL in the clinical environment (directed, collaborative, and role model SDL), with benefits and challenges of each approach.

CONCLUSIONS

This study underscores the importance of external guidance for resident SDL and expands on approaches faculty members can use to support SDL in the clinical context.

Assessing Resident Performance in Screening Mammography: Development of a Quantitative Algorithm

RATIONALE AND OBJECTIVES

This study aims to provide objective performance data and feedback, including examination volumes, recall rates, and concordance with faculty interpretations, for residents performing independent interpretation of screening mammography examinations.

METHOD AND MATERIALS

Residents (r) and faculty (f) interpret screening mammograms separately and identify non-callbacks (NCBs) and callbacks (CBs). Residents review all discordant results. The number of concordant interpretations (fCB-rCB and fNCB-rNCB) and discordant interpretations (fCB-rNCB and fNCB-rCB) are entered into a macro-driven spreadsheet. These macros weigh the data dependent on the perceived clinical impact of the resident's decision. Weighted outcomes are combined with volumes to generate a weighted mammography performance score. Rotation-specific goals are assigned for the weighted score, screening volumes, recall rate relative to faculty, and concordance rates. Residents receive one point for achieving each goal.

RESULTS

Between July 2013 and May 2017, 18,747 mammography examinations were reviewed by 31 residents, in 71 resident rotations, over 246 resident weeks. Mean resident recall rate was 9.9% and significantly decreased with resident level (R), R2 = 11.3% vs R3 = 9.4%, R4 = 9.2%. Mean resident-faculty discordance rate was 10% and significantly decreased from R2 = 12% to R4 = 9.6%. Weighted performance scores ranged from 1.1 to 2.0 (mean 1.6, standard deviation 0.17), but did not change with rotation experience. Residents had a mean goal achievement score of 2.6 (standard deviation 0.47).

CONCLUSIONS

This method provides residents with easily accessible case-by-case individualized screening outcome data over the longitudinal period of their residency, and provides an objective method of assessing resident screening mammography performance.

Using paradox theory to understand responses to tensions between service and training in general surgery

CONTEXT

The tension between service and training in pressured health care environments can have a detrimental impact on training quality and job satisfaction. Yet the management literature proposes that competing demands are inherent in organisational settings: it is not the demands as such that lead to negative outcomes but how people and organisations react to opposing tensions. We explored how key stakeholders responded to competing service-training demands in a surgical setting that had recently gone through a highly-publicised organisational crisis.

METHODS

This was an explanatory case study of a general surgery unit. Public documents informed the research questions and the data were triangulated with semi-structured interviews (n = 14) with key stakeholders. Data coding and analysis were initially inductive but, after the themes emerged, we used a paradox lens to group themes into four contextual dimensions: performing, organising, belonging and learning.

RESULTS

Tensions were apparent in the data, with managers, surgeons and trainees or residents in conflict with each other because of different goals or priorities and divergent perspectives on the same issue of balancing service and training (performing). This adversely impacted on relationships across and within groups (belonging, learning) and led to individuals prioritising their own goals rather than working for the 'greater good' (performing, belonging). Yet although relationships and communication improved, the approach to getting a better balance maintained the 'compartmentalisation' of training (organising) rather than acknowledging that training and service cannot be separated.

DISCUSSION

Stakeholder responses to the tensions provided temporary relief but were unlikely to lead to real change if the tension between service and training was considered to be an interdependent and persistent paradox. Reframing the service-training paradox in this way may encourage adjusting responses to create effective working partnerships. Our findings add to the body of knowledge on this topic, and will resonate with all those engaged in surgical and other postgraduate training.

CONTeMPLATE-a mnemonic to help medical educators infuse reflection into their residency curriculum

Reflection, where clinical experiences are analyzed to gain greater understanding and meaning, is an important step in workplace learning. Residency programs must teach their residents the skills needed for deep reflection. Medical educators may find it difficult to construct a curriculum which includes the key elements needed to enable learners to attain these skills. When we first implemented reflection into our residency curriculum, we soon realized that our curriculum only taught residents how to engage in superficial reflection. Our curriculum lacked some key elements. To help guide the transformation of our curriculum, we combed the literature for best practices. The CONTeMPLATE mnemonic was born out of this process. It is a tool to help medical educators consider and implement key elements required to enable deep reflection. The purpose of this article is to show medical educators how they can use the CONTeMPLATE mnemonic to incorporate reflective practice into their own curriculum.

Context matters when striving to promote active and lifelong learning in medical education

WHERE DO WE STAND NOW?: In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering 'self-directed and independent study' as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts.

SELF-REGULATED, LIFELONG LEARNING IN MEDICAL EDUCATION

Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. ENTRY TO PRACTICE, VOCATIONAL TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT: Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts.

Self-entrustment: how trainees' self-regulated learning supports participation in the workplace

Clinical workplaces offer postgraduate trainees a wealth of opportunities to learn from experience. To promote deliberate and meaningful learning self-regulated learning skills are foundational. We explored trainees' learning activities related to patient encounters to better understand what aspects of self-regulated learning contribute to trainees' development, and to explore supervisor's role herein. We conducted a qualitative non-participant observational study in seven general practices. During two days we observed trainee's patient encounters, daily debriefing sessions and educational meetings between trainee and supervisor and interviewed them separately afterwards. Data collection and analysis were iterative and inspired by a phenomenological approach. To organise data we used networks, time-ordered matrices and codebooks. Self-regulated learning supported trainees to increasingly perform independently. They engaged in self-regulated learning before, during and after encounters. Trainees' activities depended on the type of medical problem presented and on patient, trainee and supervisor characteristics. Trainees used their sense of confidence to decide if they could manage the encounter alone or if they should consult their supervisor. They deliberately used feedback on their performance and engaged in reflection. Supervisors appeared vital in trainees' learning by reassuring trainees, discussing experience, knowledge and professional issues, identifying possible unawareness of incompetence, assessing performance and securing patient safety. Self-confidence, reflection and feedback, and support from the supervisor are important aspects of self-regulated learning in practice. The results reflect how self-regulated learning and self-entrustment promote trainees' increased participation in the workplace. Securing organized moments of interaction with supervisors is beneficial to trainees' self-regulated learning.

Proposing a Model of Co-Regulated Learning for Graduate Medical Education

Primarily grounded in Zimmerman's social cognitive model of self-regulation, graduate medical education is guided by principles that self-regulated learning takes place within social context and influence, and that the social context and physical environment reciprocally influence persons and their cognition, behavior, and development. However, contemporary perspectives on self-regulation are moving beyond Zimmerman's triadic reciprocal orientation to models that consider social transactions as the central core of regulated learning. Such co-regulated learning models emphasize shared control of learning and the role more advanced others play in scaffolding novices' metacognitive engagement.Models of co-regulated learning describe social transactions as periods of distributed regulation among individuals, which instrumentally promote or inhibit the capacity for individuals to independently self-regulate. Social transactions with other regulators, including attending physicians, more experienced residents, and allied health care professionals, are known to mediate residents' learning and to support or hamper the development of their self-regulated learning competence. Given that social transactions are at the heart of learning-oriented assessment and entrustment decisions, an appreciation for co-regulated learning is likely important for advancing medical education research and practice-especially given the momentum of new innovations such as entrustable professional activities.In this article, the author explains why graduate medical educators should consider adopting a model of co-regulated learning to complement and extend Zimmerman's models of self-regulated learning. In doing so, the author suggests a model of co-regulated learning and provides practical examples of how the model is relevant to graduate medical education research and practice.

Self-directed Learning in Otolaryngology Residents’ Preparation for Surgical Cases

Objectives:

To characterize the nature of surgical preparation among otolaryngology residents nationwide, determine the self-rated effectiveness and efficiency of case preparation practices, and identify potential means for educational improvement.

Methods:

A survey examining the study objectives was developed and distributed to otolaryngology residents nationwide. Survey response data were submitted to descriptive analysis and comparative analyses between junior and senior residents. Literature regarding case preparation among otolaryngology residents was reviewed.

Results:

Among 108 resident respondents, the most commonly used resources included textbooks (86.1%), surgical education websites (74.1%), and surgical atlases (66.7%). Time was the primary limitation (cited by 84.3%) and convenience the predominant factor influencing resource selection (92.5%). On a 5-point Likert scale, mean scores regarding effectiveness and efficiency of case preparation were 3.53 ± 0.68 and 3.19 ± 0.88, respectively. Senior residents compared to junior residents were more likely to rate their preparation as effective (3.75 ± 0.54 vs 3.40 ± 0.72, P = .008) and efficient (3.45 ± 0.85 vs 3.03 ± 0.86, P = .02).

Conclusion:

Otolaryngology residents do not consistently rate their case preparation as effective or efficient. While there appears to be progress in self-directed learning throughout residency, room for improvement remains, with potential avenues for such improvement explored here.

A model of self-directed learning in internal medicine residency: a qualitative study using grounded theory

BACKGROUND

Existing theories of self-directed learning (SDL) have emphasized the importance of process, personal, and contextual factors. Previous medical education research has largely focused on the process of SDL. We explored the experience with and perception of SDL among internal medicine residents to gain understanding of the personal and contextual factors of SDL in graduate medical education.

METHODS

Using a constructivist grounded theory approach, we conducted 7 focus group interviews with 46 internal medicine residents at an academic medical center. We processed the data by using open coding and writing analytic memos. Team members organized open codes to create axial codes, which were applied to all transcripts. Guided by a previous model of SDL, we developed a theoretical model that was revised through constant comparison with new data as they were collected, and we refined the theory until it had adequate explanatory power and was appropriately grounded in the experiences of residents.

RESULTS

We developed a theoretical model of SDL to explain the process, personal, and contextual factors affecting SDL during residency training. The process of SDL began with a trigger that uncovered a knowledge gap. Residents progressed to formulating learning objectives, using resources, applying knowledge, and evaluating learning. Personal factors included motivations, individual characteristics, and the change in approach to SDL over time. Contextual factors included the need for external guidance, the influence of residency program structure and culture, and the presence of contextual barriers.

CONCLUSIONS

We developed a theoretical model of SDL in medical education that can be used to promote and assess resident SDL through understanding the process, person, and context of SDL.

Teaching Resident Self-Assessment Through Triangulation of Faculty and Patient Feedback

PROBLEM

To accurately determine one's ability in any clinical competency, an individual must be able to self-assess performance and identify personal limitations. Existing research demonstrates that physicians of all levels are unreliable self-assessors. This poses a concern in medical practice, which requires continuous updates to clinical competencies and awareness of personal limitations. Few published studies examine graduate medical education curricula designed to develop self-assessment skills.

INTERVENTION

Conceptual models, such as self-determination theory, suggest that self-assessment is most effectively learned through reflective processes. The Family Medicine Residency Program at Lehigh Valley Health Network developed a learner-centered competency assessment process that integrates advising and performance review. The multisource, observable behavior-based process encourages conversation between resident and advisor. Utilizing feedback from clinical preceptors and patient surveys, advisors guide residents in determining individual learning needs in core competency areas, including relationship-centered care. Development of medical learners' capacity to form relationships is one means to improving the patient experience.

CONTEXT

This retrospective case study evaluates the accuracy of senior residents' self-assessment in relationship-centered care compared with that of junior residents. The study population includes the 34 residents enrolled from AY 2009-2012. Data sets represent specific 6-month periods and have 3 component scores-Self, Faculty, and Patient-which were triangulated to determine concordance rates by postgraduate year level.

OUTCOME

The concordance rate among first-years was 26.7%, whereas third-years saw 60.0% concordance. A discordance analysis found the Patient score most often deviated from the other 2 scores, whereas the Faculty score was never the sole dissenter. When all 3 scores differed, the Self score frequently fell between the other 2 scores.

LESSONS LEARNED

The principles of self-determination theory provide a valuable framework for understanding the development of residents' intrinsic motivation to become lifelong learners. The trend in improved concordance rates among senior residents suggests that prompting learners to triangulate feedback from multiple sources can lead to a shift in perspective about competency. Further study is needed to determine whether our results are generalizable to other competencies and educational settings.

Organisation of workplace learning: a case study of paediatric residents' and consultants' beliefs and practices

Several studies have examined how doctors learn in the workplace, but research is needed linking workplace learning with the organisation of doctors' daily work. This study examined residents' and consultants' attitudes and beliefs regarding workplace learning and contextual and organisational factors influencing the organisation and planning of medical specialist training. An explorative case study in three paediatric departments in Denmark including 9 days of field observations and focus group interviews with 9 consultants responsible for medical education and 16 residents. The study aimed to identify factors in work organisation facilitating and hindering residents' learning. Data were coded through an iterative process guided by thematic analysis. Findings illustrate three main themes: (1) Learning beliefs about patient care and apprenticeship learning as inseparable in medical practice. Beliefs about training and patient care expressed in terms of training versus production caused a potential conflict. (2) Learning context. Continuity over time in tasks and care for patients is important, but continuity is challenged by the organisation of daily work routines. (3) Organisational culture and regulations were found to be encouraging as well inhibiting to a successful organisation of the work in regards to learning. Our findings stress the importance of consultants' and residents' beliefs about workplace learning as these agents handle the potential conflict between patient care and training of health professionals. The structuring of daily work tasks is a key factor in workplace learning as is an understanding of underlying relations and organisational culture in the clinical departments.

In Pursuit of Meaningful Use of Learning Goals in Residency: A Qualitative Study of Pediatric Residents

PURPOSE

Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency.

METHOD

Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory.

RESULTS

Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through.

CONCLUSIONS

Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic

BACKGROUND

This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development.

METHODS

We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctors' workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention.

RESULTS

The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind.

CONCLUSIONS

The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role.

Formative assessment in postgraduate medical education - Perceptions of students and teachers

Context:

One of the most important factors of medical education that can revolutionize the learning process in postgraduate students (PGs) is assessment for learning by means of formative assessment (FA). FA is directed at steering and fostering learning of the students by providing feedback to the learner. However, though theoretically well suited to postgraduate training, evidence are emerging that engaging stakeholders in FA in daily clinical practice is quite complex.

Aims:

To explore perceptions of PGs and teachers (Ts) about factors that determines active engagement in FA.

Subjects and Methods:

It was a descriptive qualitative study involving focus group discussions (FGDs) with PGs and Ts from Departments of Pediatrics and Orthopedics. FGDs data were processed through points/remarks, data reduction, data display, coding followed by theme generation for content analysis.

Results:

Four higher order themes emerged: Harsh reality of present summative assessment structure, individual perspectives on feedback, supportiveness of the learning environment, and the credibility of feedback and/or feedback giver.

Conclusions:

Engaging in FA with a genuine impact on learning is complex and quite a challenge to both students and Ts. Increased acceptability along with the effective implementation of FA structure, individual perspectives on feedback, a supportive learning environment and credibility of feedback are all important in this process. Every one of these should be taken into account when the utility of FA in postgraduate medical training is evaluated.

Ready, steady, go! What do histopathology trainees think they need from training to enable them to develop autonomy in surgical pathology reporting?

AIMS

This is a qualitative study of the perceived learning needs of trainees for graded responsibility in histopathological training in the UK.

METHODS

A focus group with trainees and interviews with consultants was carried out. Participants were asked 'What do you perceive are the learning needs of histopathology trainees to develop skills for safe and confident independent reporting in surgical histopathology?' Data was analysed using open coding content analysis for items relating to training content and structure.

RESULTS

Trainees and consultants perceived a need for a case load of around 100 specimens per week with a continuously variable case mix. It was thought necessary to be the principal presenter of cases at multidisciplinary team meetings. There was a perceived need for adequate amounts of supervision by consultants using double-headed microscopes and sufficient time to develop skills in microscopic visual perception through detailed feature discussion, not necessarily related to specific diagnoses. Being able to write clear histopathology reports, developing the ability to recognise normal histology and to be aware of diagnostic pitfalls were also thought to be important.

CONCLUSIONS

Our findings may inform efficacious implementation of graded responsibility in histopathology departments and be used as a sound basis for further research.

Resident Self-Assessment and Learning Goal Development: Evaluation of Resident-Reported Competence and Future Goals

OBJECTIVE

To determine incidence of learning goals by competency area and to assess which goals fall into competency areas with lower self-assessment scores.

METHODS

Cross-sectional analysis of existing deidentified American Academy of Pediatrics' PediaLink individualized learning plan data for the academic year 2009-2010. Residents self-assessed competencies in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas and wrote learning goals. Textual responses for goals were mapped to 6 ACGME competency areas, future practice, or personal attributes. Adjusted mean differences and associations were estimated using multiple linear and logistic regression.

RESULTS

A total of 2254 residents reported 6078 goals. Residents self-assessed their systems-based practice (51.8) and medical knowledge (53.0) competencies lowest and professionalism (68.9) and interpersonal and communication skills (62.2) highest. Residents were most likely to identify goals involving medical knowledge (70.5%) and patient care (50.5%) and least likely to write goals on systems-based practice (11.0%) and professionalism (6.9%). In logistic regression analysis adjusting for postgraduate year (PGY), gender, and degree type (MD/DO), resident-reported goal area showed no association with the learner's relative self-assessment score for that competency area. In the conditional logistic regression analysis, with each learner serving as his or her own control, senior residents (PGY2/3+s) who rated themselves relatively lower in a competency area were more likely to write a learning goal in that area than were PGY1s.

CONCLUSIONS

Senior residents appear to develop better skills and/or motivation to explicitly turn self-assessed learning gaps into learning goals, suggesting that individualized learning plans may help improve self-regulated learning during residency.