Not just trust: factors influencing learners' attempts to perform technical skills on real patients

Using theoretical engagement to understand workplace learning across contexts-Bringing worlds apart together

The pivotal importance of workplace learning (WPL) within health professions education has elevated its understanding and improvement to a major research priority. From a sociocultural learning theory perspective, WPL is inherently situated and context-specific. This means that the health care settings in which (future) health care professionals are trained will impact how and what is learned. However, to what extent is the research performed thus far transferable across professional contexts, cultures and borders? To what extent has WPL research sufficiently addressed the contextual characteristics of WPL to enable the evaluation of its transferability? To what extent have methodological and theoretical approaches enabled the building of understanding across contexts? We propose that heightening the transferability of WPL research as well as opening up the conversation to more diverse WPL contexts, settings and cultures will require mapping context and theoretical engagement. To explore what theoretical engagement may afford to our understanding of the influence of context on WPL, we use two theories: Landscapes of Practice and Figured Worlds. These theories with sociocultural groundings provide concrete lenses to understand the interplay between the individual and the context. We conclude with implications for research and practice and advocate for more attention to research practices that may deepen our understanding and heighten the transferability of workplace learning research.

Cherry-picking learning tasks in the orchard of postgraduate medical education - a socio-cultural perspective

'@ReneeStalmeijer and @SNEMeeuwissen use a socio‐cultural perspective, empirical examples, and the cherry‐picking metaphor, to explore interactions between trainees and healthcare teams that impact trainees’ selection of learning tasks during workplace learning

Exploring nurses' role in guiding residents' workplace learning: A mixed-method study

INTRODUCTION

Understanding residents' workplace learning could be optimized by not only considering attending physicians' role but also the role of nurses. While previous studies described nurses' role during discrete activities (e.g. feedback), a more profound understanding of how nurses contribute to residents' learning remains warranted. Therefore, we used the educational concept of guidance and explored the extent to which residents' and nurses' perceptions align regarding nurses' guiding role and which reasons they provide for their perceptions.

METHODS

This mixed-method study was conducted at four Dutch university medical centres in 2021. We simultaneously collected quantitative and qualitative data from 103 residents and 401 nurses through a theory-informed questionnaire with a Likert-scale and open-ended questions. We analyzed quantitative data to explore respondents' perceptions of nurses' guiding role by using anova. The thematically analyzed qualitative open comments explored respondents' reasons for their perceptions.

RESULTS

Nurses indicated to provide significantly more support (p = .01) and guidance on learning from patient care (p < .01) than perceived by residents. Moreover, nurses indicated that attending physicians did not always involve them in guiding residents, whereas residents perceived nurses were being involved (p < .001). Themes suggest that nurses and residents could be divided into two groups: (i) respondents who felt that guiding was inextricably linked to good interprofessional collaboration and patient care and (ii) respondents who saw the guiding role as limited and emphasised the distinct fields of expertise between nurses and physicians.

CONCLUSIONS

Residents and nurses felt that nurses played an important role in guiding residents' workplace learning. However, some residents did not always perceive to be guided. To further capitalise on nurses' guiding role, we suggest that residents can be encouraged to engage in the learning opportunities nurses provide to achieve optimal team-based patient care.

Action-project method: An approach to describing and studying goal-oriented joint actions

CONTEXT

Practicing health professionals and educators frequently act together in an interdependent or joint capacity to reach goals. Teaching or learning a new skill or engaging with patients in shared decision-making exemplifies this joint and goal-directed nature of Health Professions Education (HPE) and practice. However, building a robust understanding of the complexity of action, and joint action in particular, in HPE or patient care remains a challenge because of a limited number of methodologies available within HPE research.

METHODS

In this manuscript, we describe the Action-Project Method (A-PM) as a qualitative research approach that can be used to describe and understand goal-directed joint actions. A-PM is grounded in contextual action theory and is a methodology focussed on action as an object of study, as it is occurring. A-PM uses three distinct perspectives to understand goal-directed joint actions: observable behaviour, internal processes (i.e. reported thoughts and feelings) and the social meaning reflected in goals. Data collection in A-PM involves observations, interviews, recording of actions and a self-confrontation procedure-where participants watch video-recorded segments of action and reflect on their internal processes, describing what they were thinking or feeling as they were completing the action. Together, the rich data generated and the layered approach to analysis provide a means to better understand the joint actions embedded in complex systems and collaborative work. Furthermore, the participants are treated as equal partners within A-PM, ensuring data equity even when the research context includes hierarchical relationships.

DISCUSSION

Given increasing recognition to the importance of teamwork, relationships, interdependence, complex environments and centring patient or learner voices, A-PM is a valuable research approach for HPE. A-PM deepens our research arsenal with an approach that focusses on interdependent dyads or teams and provides a deeper understanding for how individuals engage together in goal-oriented actions.

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland

BACKGROUND

Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience.

METHODS

Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student's unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance.

RESULTS

Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P =  < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience.

CONCLUSIONS

SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.

How Clinical Supervisors Conceptualize Procedural Entrustment: An Interview-Based Study of Entrustment Decision Making in Endoscopic Training

PURPOSE

Entrustment is central to assessment in competency-based medical education (CBME). To date, little research has addressed how clinical supervisors conceptualize entrustment, including factors they consider in making entrustment decisions. The aim of this study was to characterize supervisors' decision making related to procedural entrustment, using gastrointestinal endoscopy as a test case.

METHOD

Using methods from constructivist grounded theory, the authors interviewed 29 endoscopy supervisors in the United States and Canada across multiple specialties (adult and pediatric gastroenterology, surgery, and family medicine). Semistructured interviews, conducted between April and November 2019, focused on how supervisors conceptualize procedural entrustment, how they make entrustment decisions, and what factors they consider. Transcripts were analyzed using constant comparison to generate an explanatory framework and themes.

RESULTS

Three themes were identified from the analysis of interview transcripts: (1) entrustment occurs in varying degrees and fluctuates over time; (2) entrustment decisions can transfer within and across procedural and nonprocedural contexts; (3a) persistent static factors (e.g., supervisor competence, institutional culture, legal considerations) influence entrustment decisions, as do (3b) fluctuating, situated dynamic factors (e.g., trainee skills, patient acuity, time constraints), which tend to change from one training encounter to the next.

CONCLUSIONS

In the process of making procedural entrustment decisions, clinical supervisors appear to synthesize multiple dynamic factors against a background of static factors, culminating in a decision of whether to entrust. Entrustment decisions appear to fluctuate over time, and assessors may transfer decisions about specific trainees across settings. Understanding which factors supervisors perceive as influencing their decision making has the potential to inform faculty development, as well as competency committees seeking to aggregate faculty judgments about trainee unsupervised practice. Those leading CBME programs may wish to invest in optimizing the observed static factors, such that these foundational factors are tuned to facilitate trainee learning and achievement of entrustment.

Complaint-driven preferences & trust: patient's views on consulting GP trainees

BACKGROUND

Work-based learning depends on patients' consent to have trainees involved in their care. However, patients can refuse trainees, which might lead to the loss of learning experiences. Improved understanding of patients' views on consulting trainees may provide useful insights to further optimise learning for trainees.

METHODS

We performed a qualitative study with 28 patients in The Netherlands. Participants were recruited from GP practices, and were purposively sampled on (un)willingness to consult GP trainees. In semi-structured interviews patients' perspectives and willingness to consult a trainee were explored. Transcripts were thematically analysed using an inductive approach.

RESULTS

Two themes explained patients' views on consulting GP trainees: Presenting complaint-driven preferences and Trust in trainees' capabilities. Patients select their doctor based on complaint-driven preferences and chose trainees if they fulfilled these preferences. For urgent, gender-specific and minor complaints, patients prefer timeliness, gender concordance or availability. Patients with more complex, long-term problems prefer to consult a trusted doctor with whom they have a longitudinal relationship. Through repeated visits and empathic behaviour trainees can become this doctor. Before patients consider consulting a trainee, they need to have trust in the trainee's capabilities. This trust is related to the basic trust patients have in the education of the trainee, their knowledge about trainees' capabilities and supervisory arrangements.

CONCLUSIONS

Patients' decision to visit a trainee is fluid. Patients will visit a trainee when their complaint-driven preferences are satisfied. Influencing trainees' fulfilment of these preferences and patients' trust in trainees can make patients more willing to consult trainees.

Trust and risk pitfalls in medical education: A qualitative study of clinical teachers

PURPOSE

Learning opportunities in teaching hospitals are gated by clinical teachers. One way to unpack their decision-making is to employ a 'trust and risk' model. This study aimed to uncover clinical teachers' experience of trust, risk and vulnerability as they participate in medical education.

METHODS

Hospital-based clinical teachers were interviewed about trust, risk and vulnerability in medical education. Data analysis was undertaken using a constructivist, qualitative framework.

RESULTS

Twenty demographically diverse clinical teachers participated. Trust and risk were regarded as fundamental workplace and teaching concepts. Their concerns fell into three domains of risk: clinical, teaching and personal. Being trusted unlocked clinical learning opportunities, whereas trust failure limited future participation. Feeling trusted or not affected wellbeing and self-efficacy. Trust and risk pitfalls in education included bias, asymmetry and sidelining.

CONCLUSIONS

This study adds to the literature by voicing clinical teachers' personal risks and vulnerabilities. Attention was drawn to the benefits of being perceived as trustworthy, and to the clinical, teaching and personal vulnerabilities of trust failure.If expert judgement of trustworthiness is to be legitimised as meaningful assessment, clinical teachers must be aware not only of how trust is built, but also the pitfalls of trust failure.

Transfer of training from an internal medicine boot camp to the workplace: enhancing and hindering factors

BACKGROUND

The transfer of training to the workplace is the aim of training interventions. Three primary factors influence transfer: trainee characteristics, training design and work environment influences. Within medical education, the work environment factors influencing transfer of training remain underexplored. Burke and Hutchins' review of training transfer outlined five work environment influences: opportunity to perform, supervisor/peer support, strategic link, transfer climate and accountability. This study aimed to explore the ways in which work environment factors influence the transfer of training for medical trainees.

METHODS

Internal Medicine Training in Scotland includes a three-day boot camp involving simulation-based mastery learning of procedural skills, immersive simulation scenarios and communication workshops. Following ethical approval, trainees were invited to take part in interviews at least three months after following their boot camp. Interviews were semi-structured, anonymised, transcribed verbatim and analysed using template analysis. Member checking interviews were performed to verify findings.

RESULTS

A total of 26 trainees took part in interviews between January 2020 and January 2021. Trainees reported a lack of opportunities to perform procedures in the workplace and challenges relating to the transfer climate, including a lack of appropriate equipment and resistance to change in the workplace. Trainees described a strong sense of personal responsibility to transfer and they felt empowered to change practice in response to the challenges faced.

CONCLUSIONS

This study highlights barriers to transfer of training within the clinical workplace including procedural opportunities, a transfer climate with challenging equipment availability and, at times, an unsupportive workplace culture. Trainees are driven by their own sense of personal responsibility; medical educators and healthcare leaders must harness this enthusiasm and take heed of the barriers to assist in the development of strategies to overcome them.

The wolf you feed: Challenging intraprofessional workplace-based education norms

CONTEXT

The trajectory towards becoming a medical professional is strongly situated within the clinical workplace. Through participatory engagement, medical trainees learn to address complex health care issues through collaboration with the interprofessional health care team. To help explain learning and teaching dynamics within the clinical workplace, many scholars have relied on socio-cultural learning theories. In the field of medical education, this research has largely adopted a limited interpretation of a crucial dimension within socio-cultural learning theory: the expert who guides the trainee into the community is almost exclusively from the same profession. We contend that this narrow interpretation is not necessary. This limited focus is one we choose to maintain-be that choice intentional or implicit. In this cross-cutting edge paper, we argue that choosing an interprofessional orientation towards workplace learning and guidance may better prepare medical trainees for their future role in health care practice.

METHODS

By applying Communities of Practice and Landscapes of Practice , and supported by empirical examples, we demonstrate how medical trainees are not solely on a trajectory towards the Community of Physician Practice (CoPP) but also on a trajectory towards various Landscapes of Healthcare Practice (LoHCP). We discuss some of the barriers present within health care organisations and professions that have likely inhibited adoption of the broader LoHCP perspective. We suggest three perspectives that might help to deliberately and meaningfully incorporate the interprofessional learning and teaching dynamic within the medical education continuum.

CONCLUSION

Systematically incorporating Landscapes of Competence, Assessment, and Guidance in workplace-based education-in addition to our current intraprofessional approach-can better prepare medical trainees for their roles within the LoHCP. By advocating and researching this interprofessional perspective, we can embark on a journey towards fully harnessing and empowering the health care team within workplace-based education.

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

CONTEXT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Resident competencies before and after short intensive care unit rotations: a multicentre pilot observational study

PURPOSE

Residency programs need to understand the competencies developed by residents during an intensive care unit (ICU) rotation, so that curricula and assessments maximize residents' learning. The primary study objective was to evaluate the feasibility for training programs and acceptability by residents of conducting a multi-competency assessment during a four-week ICU rotation.

METHODS

We conducted a prospective, multicentre observational pilot study in three ICUs. During weeks 1 and 4 of an ICU rotation, we conducted repeated standardized assessments of non-critical care specialty residents' competencies in cognitive reasoning (script concordance test [SCT]), procedural skills (objective structured assessment of technical skills [OSATS]-global rating scale], and communication skills through a written test, two procedural simulations, and a simulated encounter with a "family member". The feasibility outcomes included program costs, the proportion of enrolled residents able to complete at least one three-station assessment during their four-week ICU rotation, and acceptability of the assessment for the trainees.

RESULTS

We enrolled 63 (69%) of 91 eligible residents, with 58 (92%) completing at least one assessment. The total cost to conduct 90 assessments was CAD 33,800. The majority of participants agreed that the assessment was fair and that it measured important clinical abilities. For the 32 residents who completed two assessments, the mean (standard deviation) cognitive reasoning and procedural skill scores increased between weeks 1 and 4 [SCT difference, 3.1 (6.5), P = 0.01; OSATS difference for bag-mask ventilation and central line insertion, 0.4 (0.5) and 0.6 (0.8), respectively; both P ≤ 0.001]. Nevertheless, the communication scores did not change significantly.

CONCLUSIONS

A monthly multi-competency assessment for specialty residents rotating in the ICU is likely feasible for most programs with appropriate resources, and generally acceptable for residents. Specialty residents' cognitive reasoning and procedural skills may improve during a four-week ICU rotation, whereas communication skills may not.

Resident learning trajectories in the workplace: A self-regulated learning analysis

CONTEXT

Research in workplace learning has emphasised trainees' active role in their education. By focusing on how trainees fine-tune their strategic learning, theories of self-regulated learning (SRL) offer a unique lens to study workplace learning. To date, studies of SRL in the workplace tend to focus on listing the factors affecting learning, rather than on the specific mechanisms trainees use to regulate their goal-directed activities. To inform the design of workplace learning interventions that better support SRL, we asked: How do residents navigate their exposure to and experience performing invasive procedures in intensive care units?

METHODS

In two academic hospitals, we conducted post-call debriefs with residents coming off shift and later sought their elaborated perspectives via semi-structured interviews. We used a constant comparative methodology to analyse the data, to iteratively refine data collection, and to inform abductive coding of the data, using SRL principles as sensitising concepts.

RESULTS

We completed 29 debriefs and nine interviews with 24 trainees. Participants described specific mechanisms: identifying, creating, avoiding, missing and competing for opportunities to perform invasive procedures. While using these mechanisms to engage with procedures (or not), participants reported: distinguishing trajectories (i.e. becoming attuned to task-relevant factors), navigating trajectories (i.e. creating and interacting with opportunities to perform procedures), and co-constructing trajectories with their peers, supervisors and interprofessional team members.

CONCLUSIONS

We identified specific SRL mechanisms trainees used to distinguish and navigate possible learning trajectories. We also confirmed previous findings, including that trainees become attuned to interactions between personal, behavioural and environmental factors (SRL theory), and that their resulting learning behaviours are constrained and guided by interactions with peers, supervisors and colleagues (workplace learning theory). Making learning trajectories explicit for clinician teachers may help them support trainees in prioritising certain trajectories, in progressing along each trajectory, and in co-constructing their plans for navigating them.

Learning in Pediatric Emergency Situations: A Qualitative Study of Residents' Perspectives

OBJECTIVES

To explore resident learning in the context of emergency situations. The guiding research questions were: How do residents learn in emergency situations? What factors facilitate or hinder their learning?

DESIGN

A qualitative approach was used in order to understand the different perspectives of participants and explore the context of emergency situations. Aware of the complex sociocultural interactions in emergency situations, we used the methodology of constructivist grounded theory.

SETTING

A medium-sized pediatric academic hospital in San Antonio, TX.

SUBJECTS

Twenty pediatric residents participated in semi-structured interviews.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used an iterative process of data collection and analysis. The process continued until thematic saturation was reached. The data were coded and analyzed using constant comparison. Codes were clustered into themes informed by the theory of situated learning. Several methods were used to ensure trustworthiness of results. Three main themes were identified. First, resident participation in emergency situations takes different forms. Residents participate mostly in helping roles. Watching is an under-recognized form of participation yet offered unique experiences. Managing roles are rarely afforded to residents. Second, resident participation is informed by the context of the emergency situation. Based on contextual clues (e.g., safety, needs), residents infer potential risks and values from their participation, which guides their participatory role. Residents may shift their form of participation, based on changes in the context. Supervisors play a significant role in guiding resident participation. Third, engagement, a state of cognitive and emotional focus, is critical in learning. The context of the emergency situation plays a role in the level of resident engagement. Supervisors may also foster resident engagement.

CONCLUSIONS

Resident participation in emergency situations is complex and informed by the context. Learning in emergency situations is influenced by residents' level of mental engagement. Supervisors may positively guide resident participation, foster engagement, and enable them to reach their learning goals in emergency situations.

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.

Disentangling residents' engagement with communities of clinical practice in the workplace

Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members' interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community's practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents' engagement on practice, and on understanding the nuances of residents' participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs' learning affordances and residents' goals and intentions.

Trusted to Learn: a Qualitative Study of Clerkship Students' Perspectives on Trust in the Clinical Learning Environment

BACKGROUND

Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners' and supervisors' level. Research has focused on resident trainees; questions exist about how medical students experience entrustment.

OBJECTIVE

This study examines how clerkship students perceive supervisors' trust in them and its impact on their learning.

DESIGN

Qualitative study using individual semi-structured interviews.

PARTICIPANTS

Clerkship medical students at the University of California, San Francisco.

APPROACH

We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis.

KEY RESULTS

Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students' motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy.

CONCLUSIONS

As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.

An inconvenient discussion

This commentary argues for the importance of informing patients about their participation in medical education when being cared for by trainees.