Residents in difficulty: a mixed methods study on the prevalence, characteristics, and sociocultural challenges from the perspective of residency program directors

"I'm on an island": A qualitative study of underperforming surgical trainee perspectives on remediation

BACKGROUND

There is a significant gap in the literature regarding trainees' perceptions of remediation. This study aims to explore surgical trainees' experiences and perspectives of remediation.

METHODS

This qualitative study used semi-structured interviews with 11 doctors who have experienced formal remediation as a surgical trainee. Reflexive thematic analysis was used for data analysis.

RESULTS

In this study, trainees perceived remediation as a harrowing and isolating experience, with long-lasting emotions. There was a perceived lack of clarity regarding explanations of underperformance and subjective goals. Remediation was viewed as a 'performance' and tick-box exercise with superficial plans, with challenging trainee/supervisor dynamics.

CONCLUSIONS

These findings about trainees' perspectives on remediation show a need for trainees to be better emotionally supported during remediation and that remediation plans must be improved to address deficits. Integrating the perspectives and experiences of surgical trainees who have undergone remediation should help improve remediation outcomes and patient care.

Beyond theoretical courses - A study of Swedish psychiatric residents' collegial learning through conversations in the workplace

BACKGROUND

Collegial conversations are important for sustainable learning to last beyond a course. Research on collegial conversations and peer learning in the workplace during psychiatric residency courses remains sparse, however. In this study, the aim was to explore residents' opportunities for collegial conversations during and after national courses in psychiatry.

METHODS

Residents in psychiatry completed an online survey including questions on opportunities for collegial conversations in their workplaces. Logistic regression was used for multivariate analysis and thematic content analysis was used for the open-ended answers where a theoretical framework of communities of practice was employed for the interpretation of the findings.

RESULTS

The survey was completed by 112 residents out of 725 (15,4%). The participants reported few structured forums for collegial discussion. The results of multivariate analysis suggest that more women than men feel it is advantageous to attend courses with others from the same workplace or from the same group of residents, described here as a team. The analysis of qualitative data identified how opportunities for collegial conversations differ across contexts and the type of values that are attached to team participation in residency courses.

CONCLUSIONS

This study highlights the importance of collegial conversations as a way to sustain the learning from residency courses into the workplace. By learning about residents' perceptions of collegial conversations during and after courses, teachers and directors may be more able to support residents' lifelong learning and professional development.

Is insufficient introspection a reason to terminate residency training? - Scrutinising introspection among residents who disputed dismissal

INTRODUCTION

Insufficient introspection as part of the 4I's model of medical professionalism (introspection, integrity, interaction, and involvement) is considered an important impediment in trainees. How insufficient introspection relates to decisions to terminate residency training remains unclear. Insights into this subject provide opportunities to improve the training of medical professionals.

METHODS

We analysed the Dutch Conciliation Board decisions regarding residents dismissed from training between 2011 and 2020. We selected the decisions on residents deemed 'insufficient' regarding introspection as part of the CanMEDS professional domain and compared their characteristics with the decisions about residents without reported insufficiencies on introspection.

RESULTS

Of the 120 decisions, 86 dismissed residents were unable to fulfil the requirements of the CanMEDS professional domain. Insufficient introspection was the most prominent insufficiency (73/86). These 73 decisions described more residents' insufficiencies in CanMEDS competency domains compared to the rest of the decisions (3.8 vs. 2.7 p < 0.001), without significant differences regarding gender or years of training.

CONCLUSIONS

Insufficient introspection in residents correlates with competency shortcomings programme directors reported in dismissal disputes. The 4I's model facilitates recognition and description of unprofessional behaviours, opening avenues for assessing and developing residents' introspection, but further research is needed for effective implementation in medical education.

Tutor Uncertainty in Dealing with Unprofessional Behaviours of Medical Students and Residents: a Mixed Methods Study

BACKGROUND

Despite acknowledgement of medical students' expected professional behaviours and attitudes, there remains widespread reluctance to report students that behave inappropriately. Existing literature focuses on why faculty fail to fail, overlooking the tutors who deal with students day to day. We investigated how tutors address inappropriate behaviours and attitudes in students and residents.

METHODS

A mixed methods study was carried out consisting of a survey and two focus groups with tutors. Seventeen tutors from the University of Limerick School of Medicine, Ireland, took part in the survey (n = 22%) and eight tutors participated in two focus groups during the 2018-2019 academic year.

RESULTS

Findings suggested that 59% of tutors would take a different approach to addressing unprofessional behaviours witnessed in medical students and residents. A total of 88% of tutors said they intervened on a professionalism issue with 52% saying 'once in a while'. In contrast to the survey, tutors in the focus groups expressed a lack of confidence in addressing some behaviours due to a lack of time, not seeing the outcome of process/remediation etc. Tutors indicated a strong preference for case-based training on assessing professional identity formation (PIF).

CONCLUSIONS

We found tutors typically work closely with students on a day-to-day basis managing unprofessionalism issues. Tutors valued regular communication about policies and procedures about appropriate conduct as well as support, advice, and/or oversight from independent members of university staff. This research highlights the need for training designed for busy tutors as a distinct type of medical teacher.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01429-1.

Seeing but not believing: Insights into the intractability of failure to fail

CONTEXT

Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee.

METHODS

Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place.

RESULTS

Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility.

CONCLUSION

Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.

Struggling urology trainee: a qualitative study into causes of underperformance

BACKGROUND

Urological surgical trainees who underperform are difficult to identify, manage and require significant resources in an already stretched system relying on pro bono supervisors that often have no formal training. While there are commentaries on how to manage underperforming surgical trainees, there is a lack of data detailing the complex reasons for underperformance. It is important to understand the complexities contributing to underperformance so that improved remediation plans can be developed which can better help trainees meet expectations and succeed.

METHODS

In this qualitative study, individual semi-structured interviews were conducted with key persons identified as having very high levels of background knowledge and involvement with current underperforming urological surgery trainees. Transcribed interviews were thematically analysed.

RESULTS

Ten interviews were conducted, including nine urology consultants and one educational manager. Five themes were identified: underperformance is a small but profound issue; spiral of failure; the changing trainee; lack of insight and under supported supervisors and posts.

CONCLUSION

Causes of underperformance in urology trainees are complex and multifactorial. Behavioural issues were considered the most likely cause, which are also the most challenging to remedy. However, in addition to trainee factors, causative factors related to supervision and training were identified. Addressing all of these issues is paramount if effective remediation of these trainees is to occur.

The Swansea 6D model: a diagnostic and conversational framework for supervisors, mentors and doctors in training

Doctors in training are particularly vulnerable to stress and burnout, with the transition into the early parts of training being a period of acute anxiety. Supervisors and mentors have a key role to play in helping trainees make the transition from medical student to practising doctor. This often involves professional conversations, ranging from the relatively routine to difficult issues. The Swansea 6D model has been designed as a guidance tool which provides a simple, memorable framework around which conversations can be structured in terms of identifying meaningful expectations, providing explanations and reframing situations.