How core competencies are taught during clinical supervision: participatory action research in family medicine

Establishing competency based internship program through participatory action research in a private pharmacy college in the Eastern Province of Saudi Arabia

Objectives

To use Participatory Action Research (PAR) methodology to develop a competency-based training (CBT) program for Bachelor of Pharmacy interns at Mohammed Al-Mana College for Medical Sciences (MACHS), Dammam, Saudi Arabia, based on the International Pharmaceutical Federation (FIP) Global Competency Framework.

Methods

The MACHS Pharmacy Department Training Unit developed a competency-based training (CBT) framework over 6 cohorts of interns based on the FIP Global Competency Framework using the Participatory Action Research (PAR) methodology. Assignments were set throughout the training period to support competency development. Assessment methods used for the evaluation included student portfolio, site preceptor evaluation and the college-based assessments. End of training and baseline results were compared to determine the effectiveness of CBT in terms of improvement of skills. Problems were identified and action plans developed, to be implemented on the following cohort. Successful completion of CBT required a total score of 80%. The students who could not pass the assessment were given a chance to improve their weak competencies and retake the assessment.

Results

Since its implementation, five cohorts have been trained through CBT. Only 12% of interns passed the training in first attempt in the first cohort. This passing percentage dramatically increased to 75-100% in the consecutive cohorts where students scored better in the portfolio, and site preceptor evaluation as compared to the college-based assessment. Students' feedback towards the assignments was positive.

Conclusion

Participatory Action Research was found to be an effective approach towards developing a competency-based training program for Pharmacy interns. More FIP competencies and evaluation strategies will be added to the internship program in the future. Furthermore, a national approach towards implementation of CBT should be used to ensure the uniformity of competency of pharmacists across the kingdom.

The cognitive apprenticeship model as a framework for desired precepting qualities to inform preceptor development

INTRODUCTION

Positive learner perceptions of learning experiences have been linked to better learning outcomes. More information is needed on learners' desired qualities of preceptors and learning experiences to inform preceptor development. Aligning learners' perceptions with a teaching framework, such as the Cognitive Apprenticeship (CA) framework, may be useful to guide preceptor self-assessment and development. However, information is lacking regarding whether the CA framework is consistent with learners' expectations. The purpose of this study was to determine pharmacy learner perspectives on desired preceptor behaviors and qualities and to evaluate their alignment with the CA framework to inform preceptor development.

METHODS

Twenty-two learners (nine residents and 13 introductory and advanced pharmacy practice students) participated in nine focus group interviews. Data were analyzed qualitatively by inductive coding and pattern coding and then condensed into themes. After initial analysis, the CA framework was adapted into codes and applied to the data to explore the alignment of quality preceptor characteristics with CA.

RESULTS

Learners identified desired general preceptor characteristics, teaching behaviors, and qualities of sites and experience structure in their discussion. All four CA dimensions (Methods, Sociology, Sequencing, and Content) were represented in the described desired preceptor qualities. Most comments were connected to the Methods dimension.

CONCLUSIONS

This study supports the use of CA as a framework to guide preceptor development and assessment for desired precepting qualities, preceptor behaviors, and learning environments. Additional research is needed for best practices in implementing CA in preceptor assessment and professional development.

Positioning, power and agency in postgraduate primary care supervision: a study of trainee narratives

BACKGROUND

Postgraduate supervision takes place within complex training environments, where experiences are shaped by the socio-cultural context and wider profession, and where tensions permeate. Bordin's working alliance-based model of supervision suggests that quality relationships encompass agreement on the goals and tasks of supervision, in the context of an emotional bond. However, as trainees and their supervisors navigate the demands of providing safe clinical care, alongside educational support, disagreement on expectations for supervision may emerge. By applying a critical lens, this research draws on positioning theory to explore General Practice trainees' experiences of supervision.

METHODS

In 2017-2019 a series of narrative interviews were undertaken with 13 General Practice trainees in the United Kingdom (UK). Participants were purposively sampled based on end-of-year performance, gender, training location and training status. Interviews were analysed using Brown and Gilligan's Listening Guide, which was adapted to incorporate an exploration of positioning, power and agency.

RESULTS

Trainees appeared to hold variable positions, such as 'insiders', 'outsiders', 'peers' and 'problem trainees'. Supervisors, through talk and the degree of access afforded, contributed to this positioning. Some trainees viewed their supervisors as brokers and guides as they navigated their training, whilst others were suspicious of the supervisor role. For trainees who raised concerns about their supervisor through formal channels, results were not often satisfactory. Others chose to navigate difficulty in supervision through informal means. This typically involved mastery of artefacts of training, such as the electronic appointment book or training portfolio.

CONCLUSIONS

This paper builds on Bordin's model of supervision to encourage greater clarity in supervisory discussions, exploring assumptions, and recognising the influences of environment, power, positioning, and agency. We have developed a Model of the Supervisory Alliance in Postgraduate GP Training (MSA-GP) to serve as a springboard for discussion for trainees and their supervisors.

[Acquiring general practitioner roles during the outpatient postgraduate training section and profession-forming postgraduate training conditions in family physician practices - A survey among family medicine residents in Rhineland-Palatinate during their postgraduate training in general medicine]

BACKGROUND

Postgraduate training in general medicine should be oriented on competencies and profession-forming, as is suggested by the German Regulations on Specialist Training of federal and state governments and the Competence-based Curriculum General Medicine. The learnability of general practitioner (GP) roles and the profession-forming orientation of the postgraduate training conditions during the outpatient postgraduate training period were investigated.

METHODS

A cross-sectional study in questionnaire design was conducted from October until December 2019 among 220 physicians in postgraduate training who were registered at the Association of Statutory Health Insurance-Accredited Physicians in Rhineland-Palatinate for the specialty of general medicine. The GP roles surveyed were based on the "CanMEDS General Medicine" roles. Using indicators created from the didactic model "Cognitive Apprenticeship", profession-forming alignment of postgraduate training conditions in the GP practices were studied. The data obtained were analysed descriptively.

RESULTS

The response of 70 evaluable questionnaires included a gender distribution of 51 female and 18 male family medicine residents. The family medicine residents were almost equally divided between single-handed practices, cooperating practice associations and group practices. Slightly more than half of the female physicians worked part-time, whereas the male physicians were all full-time employees. The roles of "member of an interprofessional team", "health advocate" and "medical expert" were perceived as learnable by 70 to 90% of the family medicine residents. In addition to approval, varying degrees of indecision and rejection were expressed regarding the learnability of the roles of "teacher/scholar", "member of a network" and "employer". A slight majority considered the appropriation of the role of "practice manager" to be critical. Within the survey of profession-forming postgraduate training conditions, the indicators "accessible contact person", "collegial appreciation" and "assumption of responsibility" were approved by more than 90% in some cases. The indicators "access to GP acting" (approx. 86%) and "resilience" (approx. 71%) also received high approval ratings. However, the indicator "continuous feedback" only received a slight majority of approval.

DISCUSSION

GP postgraduate training practices in Rhineland-Palatinate apparently offer suitable educational locations to family medicine residents to acquire a solid basis for professional practising and the skills for patient-oriented communicating of preventive health-promoting contents. Male physicians seem to follow more traditional professional hierarchies. In contrast, female physicians are more receptive to teamwork but tend to be sceptical about adopting a leadership position. The learnability of particular GP roles may benefit from close collaboration with the practice owner, especially in single-handed practices. In addition, the working time model chosen seems to have an effect.

CONCLUSIONS

It can be assumed that profession-forming postgraduate training conditions predominate in Rhineland-Palatinate GP postgraduate training practices, where the role of "medical expert" also appeared to be learnable in most cases. The learnability of GP roles were influenced by the factors "gender", "working time model" and "form of practice" in some cases significantly. Consequently, it could have a quality-enhancing impact if these factors were taken into account in the development of measures to realize competence orientation in GP postgraduate training.

Implementation of Patient-Centered Care by Athletic Training Students during Clinical Experiences: A Report from the Association of Athletic Training Education Research Network

Patient-centered care (PCC) is a core competency that should be required by all healthcare education programs, but little is known about its implementation in athletic training clinical experiences. Therefore, we examined characteristics of patient encounters documented by athletic training students implementing PCC behaviors. A multisite panel design was used to recruit 363 students from twelve professional athletic training programs (five undergraduate, seven graduate). Over 1.5 years, clinical experience patient encounter data were logged in E*Value Case Logs, including student role during the encounter, length of encounter, and clinical site. Generalized estimating equations models characterized the likelihood students included PCC behaviors in 30,522 encounters. Discussing patient goals was associated with student role (χ²(2) = 40.6, p < 0.001) and length of encounter (χ²(4) = 67.6, p < 0.001). Using patient-reported outcome measures was associated with student role (χ²(2) = 21.6, p < 0.001), length of encounter (χ²(4) = 34.5, p < 0.001), and clinical site (χ²(3) = 17.3, p = 0.001). Implementing clinician-rated outcome measures was affected by length of encounter (χ²(4) = 27.9, p < 0.001) and clinical site (χ²(3) = 8.6, p = 0.04). PCC behaviors were largely associated with student role and length of encounters; clinical site had less impact. Athletic training educators should emphasize progressive autonomous supervision with preceptors and encourage students to facilitate slightly longer patient visits, when possible, to incorporate more PCC behaviors.

The effects of cognitive apprenticeship and co-regulated learning on improving students’ computer problem-solving skills, learning motivation, and exp

This study makes use of online teaching in this environment and adopts it for use in a required computer skills course with Cognitive apprenticeship (CA) and Co-regulated learning (CRL) teaching methods to improve students’ computer skills, learning motivation, and experience of online learning. The subjects of this study are first-year students of a non-information-related department at a private university in northern Taiwan. A total of four classes comprising 111 students participated in the research. The CRL and CA group (C1, n=24) concurrently received CRL and CA treatments; the non-CRL and CA group (C2, n=25) received only the CA teaching method, and the CRL and non-CA group (C3, n=40) only the teaching method of CRL. The non-CRL and non-CA group (C4, n=22) served as the control group. The results show that the use of CA can significantly improve students’ computer skills; however, the expected effects of CRL were not found in this study.

Analysis of Supervisors' Feedback to Residents on Communicator, Collaborator, and Professional Roles During Case Discussions

BACKGROUND

Literature examining the feedback supervisors give to residents during case discussions in the realms of communication, collaboration, and professional roles (intrinsic roles) focuses on analyses of written feedback and self-reporting.

OBJECTIVES

We quantified how much of the supervisors' verbal feedback time targeted residents' intrinsic roles and how well feedback time was aligned with the role targeted by each case. We analyzed the educational goals of this feedback. We assessed whether feedback content differed depending on whether the residents implied or explicitly expressed a need for particular feedback.

METHODS

This was a mixed-methods study conducted from 2017 to 2019. We created scripted cases for radiology and internal medicine residents to present to supervisors, then analyzed the feedback given both qualitatively and quantitatively. The cases were designed to highlight the CanMEDS intrinsic roles of communicator, collaborator, and professional.

RESULTS

Radiologists (n = 15) spent 22% of case discussions providing feedback on intrinsic roles (48% aligned): 28% when the case targeted the communicator role, 14% for collaborator, and 27% for professional. Internists (n = 15) spent 70% of discussions on intrinsic roles (56% aligned): 66% for communicator, 73% for collaborator, and 72% for professional. Radiologists' goals were to offer advice (66%), reflections (21%), and agreements (7%). Internists offered advice (41%), reflections (40%), and clarifying questions (10%). We saw no consistent effects when residents explicitly requested feedback on an intrinsic role.

CONCLUSIONS

Case discussions represent frequent opportunities for substantial feedback on intrinsic roles, largely aligned with the clinical case. Supervisors predominantly offered monologues of advice and agreements.

Conceptualization of Competency-Based Medical Education Terminology in Family Medicine Postgraduate Medical Education and Continuing Professional Development: A Scoping Review

PURPOSE

To examine the extent, range, and nature of how competency-based medical education (CBME) implementation terminology is used (i.e., the conceptualization of CBME-related terms) within the family medicine postgraduate medical education (PGME) and continuing professional development (CPD) literature.

METHOD

This scoping review's methodology was based on Arksey and O'Malley's framework and subsequent recommendations by Tricco and colleagues. The authors searched 5 databases and the gray literature for U.S. and Canadian publications between January 2000 and April 2017. Full-text English-language articles on CBME implementation that focused exclusively on family medicine PGME and/or CPD programs were eligible for inclusion. A standardized data extraction form was used to collect article demographic data and coding concepts data. Data analysis used mixed methods, including quantitative frequency analysis and qualitative thematic analysis.

RESULTS

Of 470 unique articles identified, 80 (17%) met the inclusion criteria and were selected for inclusion in the review. Only 12 (15%) of the 80 articles provided a referenced definition of the coding concepts (i.e., referred to an article/organization as the definition's source), resulting in 19 highly variable-and 12 unique- referenced definitions of key terms used in CBME implementation (competence, competency, competency-based medical education). Thematic analysis of the referenced definitions identified 15 dominant themes, among which the most common were (1) a multidimensional and dynamic concept that encompasses a variety of skill components and (2) being able to use communication, knowledge, technical skills, clinical reasoning, judgment, emotions, attitudes, personal values, and reflection in practice.

CONCLUSIONS

The construction and dissemination of shared definitions is essential to CBME's successful implementation. The low number of referenced definitions and lack of consensus on such definitions suggest more attention needs to be paid to conceptual rigor. The authors recommend those involved in family medicine education work with colleagues across medical specialties to develop a common taxonomy.

Improved cognitive apprenticeship clinical teaching after a faculty development program

BACKGROUND

While it is well known that the cognitive apprenticeship is an effective workplace-based teaching approach for clinical teachers, the effects of faculty development (FD) have not been analyzed from that perspective. The purpose of this study was to investigate self-assessment by clinical teachers of their educational perceptions and behaviors after a FD program using the cognitive apprenticeship model.

METHODS

Board-certified pediatricians who participated in a 3-day FD program on practical clinical teaching were asked to complete questionnaires. Fifty participants completed two questionnaires prior to and 3 and 6 months after the FD program: the first was on the participants' general perceptions and behaviors in relation to their own clinical education and the second was a self-assessment using the Maastricht Clinical Teaching Questionnaire (MCTQ) that was developed based on the cognitive apprenticeship model.

RESULTS

The general survey demonstrated that 78% of the participants experienced positive changes in their educational perceptions 6 months after FD. Self-assessment using the MCTQ showed that the scores in the categories of "articulation," "exploration," and "safe learning environment" remained significantly improved 6 months after the FD program.

CONCLUSIONS

The participants' self-perceived improvement in behaviors was sustainable for 6 months after participation the FD program. The results of the MCTQ show that through their experiences in the FD program, the participants seemingly transformed their clinical teaching to become interactive facilitators, encouraging self-directed learning. Our results also suggest that the MCTQ can be used for self-assessment of clinical teachers and to enhance the effectiveness of the FD program.

A systematic review of supervisory relationships in general practitioner training

OBJECTIVES

The educational alliance is argued to be at the heart of supervision in medical education. This review aims to map the research field and develop a conceptualisation of the nature of such educational alliances within postgraduate supervision for general practitioners.

METHODS

An integrative review of the international literature on supervision from 2011 to 2018 was undertaken, and papers assessed for relevance and quality. Data analysis incorporated framework analysis techniques. Bordin's working alliance-based model of supervision was used as a springboard for synthesis, as well as allowing for the emergence of new ideas, theories and concepts from the literature.

RESULTS

A total of 49 full texts were included for analysis. There was evidence of the importance of trust, agreement and bond in accordance with Bordin's model. The results also highlighted the importance of greater clarity on supervisory goals, and the tasks to support these goals, to effectively address competing priorities and roles within supervision. Non-hierarchical relationships were advocated, although supervisors must remain impartial in their assessment and monitoring roles. The influence of the wider practice community and situated learning through legitimate peripheral participation are documented. A model of General practice (GP) supervision is proposed that integrates the findings.

CONCLUSIONS

GP supervision requires a greater emphasis than is suggested by the working alliance model, both on the clarity of expectations and the appreciation of the multiple roles and competing priorities of both trainee and supervisor. Furthermore, as GP supervision develops within the rising workload of contemporary general practice, the role of the wider community of practice may become more prominent. We have adapted the working alliance model for postgraduate General practice (GP) supervision, emphasising the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement.

Comparing resident-patient encounters and case presentations in a family medicine clinic

OBJECTIVES

Oral case presentations following resident-patient interactions provide the primary mechanism by which faculty supervisors assess resident competence. However, the extent to which these presentations capture the content and quality of resident-patient communication during the encounter remains unknown. We aimed to determine whether: (i) the resident-patient encounter content matched information conveyed in the case presentation; (ii) the quality of resident-patient communication was accurately conveyed, and (iii) supervisors addressed effective and ineffective communication processes.

METHODS

A total of 22 pairs of resident-patient encounters and family medicine resident case presentations were video- or audiorecorded, transcribed and compared for content. Resident-patient communication was assessed using adapted versions of the Calgary-Cambridge Guide to the Medical Interview and Explanation and Planning Scale.

RESULTS

Interviews and presentations contained largely congruent content, but social history and the patient's perspective were consistently excluded from case presentations. Although six of 19 specific communication skills were used in over 80% of resident encounters, the effective use of communication skills was widely variable. In most presentations, the quality of resident-patient communication was not explicitly conveyed to the supervisor. Although resident presentations provided 'cues' about communication issues, supervisors rarely responded.

CONCLUSIONS

This study lends support to direct observation in workplace-based learning of communication skills. When content areas such as the patient's perspective and education are excluded, supervisors cannot address them. In addition, presentations provided minimal insight about the quality of resident-patient encounters and limited the ability to address communication skills. These skills could be enhanced by attending to communication cues during case presentations, making increased use of direct observation and feedback, and promoting faculty development to address these missed teaching opportunities.

Athletic Training Student Core Competency Implementation During Patient Encounters

CONTEXT

  Health care research evidence suggests that early patient encounters (PEs), as well as the purposeful implementation of professional core competencies (CCs), for athletic training students (ATSs) may be beneficial to their ability to provide care. However, no investigators have related facets of the clinical education experience with CC implementation as a form of summative assessment of the clinical experience.

OBJECTIVE

  To determine the relationship between the frequency and length of PEs, as well as the student's role and clinical site during PEs, and the students' perceived CC implementation during these encounters.

DESIGN

  Cross-sectional study.

SETTING

  Professional athletic training program, National Collegiate Athletic Association Division I institution.

PATIENTS OR OTHER PARTICIPANTS

  We purposefully recruited 1 athletic training program that used E*Value software; 40 participants (31 females, 9 males) enrolled in the professional phase (12 first year, 14 second year, 14 third year) participated.

INTERVENTION(S)

  Participants viewed a 20-minute recorded CC educational module followed by educational handouts, which were also posted online for reference throughout the semester. The E*Value software was used to track PEs, including the type of encounter (ie, actual patient, practice encounter, didactic practice scenario), the type of site where the encounter occurred (university, high school), and the participant's role (observed, assisted, performed), as well as responses to an added block of questions indicating which, if any, of the CCs were implemented during the PE.

MAIN OUTCOME MEASURE(S)

  Variables per patient were PE length (minutes), participant role, site at which the encounter occurred, and whether any of the 6 CCs were implemented ( yes/ no). Variables per participant were average encounter length (minutes), encounter frequency, modal role, clinical site assignment, and the number of times each CC was implemented. Separate 1-way analyses of variance were used to examine the relationships between role or clinical site and implementation of total number of CCs. Multiple linear regressions were used to determine how the average length and frequency of PEs were related to the average and total number of implemented CCs. Binary logistic regression models indicated how the length of each encounter, role of the participant, and type of clinical site related to the implementation of each CC.

RESULTS

  The roles of participants during PEs were related to their ability to implement the total number of CCs ( F = 103.48, P < .001). Those who observed were likely to implement fewer total CCs than those who assisted (M diff = -0.29, P < .001); those who assisted were likely to implement more total CCs than those who performed (M diff = 0.32, P < .001). Frequency of encounters was the only significant variable in the model examining all independent variables with CC implementation ( b_4,32 = 3.34, t = 9.46, P < .001).

CONCLUSIONS

  The role of the student, namely assisting during PEs, and the volume of PEs should be considered priorities for students to promote greater CC implementation.

Identifying the Presence of Cognitive Apprenticeship in the Layered Learning Practice Model

Objective. To identify the presence of cognitive apprenticeship themes in the layered learning practice model (LLPM). Methods. Attending pharmacists who had implemented an LLPM completed an individual 90-minute face-to-face semi-structured interview. Three researchers independently reviewed transcripts to identify cognitive apprenticeship themes according to the framework's dimensions and sub-dimensions. Results. Of 25 eligible attending pharmacists, 24 (96%) agreed to participate. All core dimensions of the cognitive apprenticeship framework emerged during the interviews; however, preceptors varied in how they used the framework in the training of pharmacy learners at different levels. This variability was especially apparent within the sub-dimensions of the content and method domains. Conclusion. This study demonstrates that all four cognitive apprenticeship principles are being used in the clinical environments operationalizing the LLPM. These findings suggest that cognitive apprenticeship is an applicable and relevant educational framework when engaging multiple learners in clinical education environments.

Cognitive apprenticeship in health sciences education: a qualitative review

Cognitive apprenticeship theory emphasizes the process of making expert thinking "visible" to students and fostering the cognitive and meta-cognitive processes required for expertise. The purpose of this review was to evaluate the use of cognitive apprenticeship theory with the primary aim of understanding how and to what extent the theory has been applied to the design, implementation, and analysis of education in the health sciences. The initial search yielded 149 articles, with 45 excluded because they contained the term "cognitive apprenticeship" only in reference list. The remaining 104 articles were categorized using a theory talk coding scheme. An in depth qualitative synthesis and review was conducted for the 26 articles falling into the major theory talk category. Application of cognitive apprenticeship theory tended to focus on the methods dimension (e.g., coaching, mentoring, scaffolding), with some consideration for the content and sociology dimensions. Cognitive apprenticeship was applied in various disciplines (e.g., nursing, medicine, veterinary) and educational settings (e.g., clinical, simulations, online). Health sciences education researchers often used cognitive apprenticeship to inform instructional design and instrument development. Major recommendations from the literature included consideration for contextual influences, providing faculty development, and expanding application of the theory to improve instructional design and student outcomes. This body of research provides critical insight into cognitive apprenticeship theory and extends our understanding of how to develop expert thinking in health sciences students. New research directions should apply the theory into additional aspects of health sciences educational research, such as classroom learning and interprofessional education.

Towards tailored teaching: using participatory action research to enhance the learning experience of Longitudinal Integrated Clerkship students in a South African rural district hospital

BACKGROUND

The introduction of Stellenbosch University's Longitudinal Integrated Clerkship (LIC) model as part of the undergraduate medical curriculum offers a unique and exciting training model to develop generalist doctors for the changing South African health landscape. At one of these LIC sites, the need for an improvement of the local learning experience became evident. This paper explores how to identify and implement a tailored teaching and learning intervention to improve workplace-based learning for LIC students.

METHODS

A participatory action research approach was used in a co-operative inquiry group (ten participants), consisting of the students, clinician educators and researchers, who met over a period of 5 months. Through a cyclical process of action and reflection this group identified a teaching intervention.

RESULTS

The results demonstrate the gaps and challenges identified when implementing a LIC model of medical education. A structured learning programme for the final 6 weeks of the students' placement at the district hospital was designed by the co-operative inquiry group as an agreed intervention. The post-intervention group reflection highlighted a need to create a structured programme in the spirit of local collaboration and learning across disciplines. The results also enhance our understanding of both students and clinician educators' perceptions of this new model of workplace-based training.

CONCLUSIONS

This paper provides practical strategies to enhance teaching and learning in a new educational context. These strategies illuminate three paradigm shifts: (1) from the traditional medical education approach towards a transformative learning approach advocated for the 21(st) century health professional; (2) from the teaching hospital context to the district hospital context; and (3) from block-based teaching towards a longitudinal integrated learning model. A programme based on balancing structured and tailored learning activities is recommended in order to address the local learning needs of students in the LIC model. We recommend that action learning sets should be developed at these LIC sites, where the relevant aspects of work-place based learning are negotiated.