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Rietmeijer CBT, van Esch SCM, Blankenstein AH, van der Horst HE, Veen M, Scheele F, Teunissen PW. A phenomenology of direct observation in residency: Is Miller's 'does' level observable? MEDICAL EDUCATION 2023; 57:272-279. [PMID: 36515981 PMCID: PMC10107098 DOI: 10.1111/medu.15004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Guidelines on direct observation (DO) present DO as an assessment of Miller's 'does' level, that is, the learner's ability to function independently in clinical situations. The literature, however, indicates that residents may behave 'inauthentically' when observed. To minimise this 'observer effect', learners are encouraged to 'do what they would normally do' so that they can receive feedback on their actual work behaviour. Recent phenomenological research on patients' experiences with DO challenges this approach; patients needed-and caused-some participation of the observing supervisor. Although guidelines advise supervisors to minimise their presence, we are poorly informed on how some deliberate supervisor participation affects residents' experience in DO situations. Therefore, we investigated what residents essentially experienced in DO situations. METHODS We performed an interpretive phenomenological interview study, including six general practice (GP) residents. We collected and analysed our data, using the four phenomenological lenses of lived body, lived space, lived time and lived relationship. We grouped our open codes by interpreting what they revealed about common structures of residents' pre-reflective experiences. RESULTS Residents experienced the observing supervisor not just as an observer or assessor. They also experienced them as both a senior colleague and as the patient's familiar GP, which led to many additional interactions. When residents tried to act as if the supervisor was not there, they could feel insecure and handicapped because the supervisor was there, changing the situation. DISCUSSION Our results indicate that the 'observer effect' is much more material than was previously understood. Consequently, observing residents' 'authentic' behaviour at Miller's 'does' level, as if the supervisor was not there, seems impossible and a misleading concept: misleading, because it may frustrate residents and cause supervisors to neglect patients' and residents' needs in DO situations. We suggest that one-way DO is better replaced by bi-directional DO in working-and-learning-together sessions.
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Affiliation(s)
- Chris B. T. Rietmeijer
- Department of General PracticeAmsterdam UMC, location Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Suzanne C. M. van Esch
- Department of General PracticeAmsterdam UMC, location University of AmsterdamAmsterdamThe Netherlands
| | - Annette H. Blankenstein
- Department of General PracticeAmsterdam UMC, location Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Henriëtte E. van der Horst
- Department of General PracticeAmsterdam UMC, location Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Mario Veen
- Department of General PracticeErasmus Medical CenterRotterdamThe Netherlands
| | - Fedde Scheele
- School of Medical Sciences, Athena Institute for Transdisciplinary ResearchAmsterdam UMC, location Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Pim W. Teunissen
- School of Health Professions EducationMaastricht UniversityMaastrichtThe Netherlands
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Sari SM, Suhoyo Y, Mulyana D, Claramita M. The interactional communication of feedback in clinical education: A focused ethnographic study in a hierarchical and collectivist culture. Heliyon 2023; 9:e14263. [PMID: 36938453 PMCID: PMC10019999 DOI: 10.1016/j.heliyon.2023.e14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 02/12/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Background The definition of feedback in clinical education has shifted from information delivery to student-teacher dialogue. However, based on Hofstede's theory, countries with large power distance or a robust social hierarchy and collectivistic cultural dimensions can reduce the feedback dialogue to a minimum. Indonesia is classified in this group, with some Asian, African, Mediterranean, and Latin American countries. This study explores the interactional communication of feedback during clinical education in a hierarchical and collectivistic context. Methods The focused ethnographic approach was applied to the clinical rotation program in an Indonesian teaching hospital. Data sources included observations of feedback episodes during workplace-based assessments followed by interviews with clinical supervisors and students. The data were compiled within 16 weeks of observation in 7 groups of clinical departments, consisting of 28 field notes, audiotaped interviews including nine focus group discussions of students (N = 42), and seven in-depth interviews with clinical supervisors. Data were analyzed through transcription, coding, categorization, and thematic analysis using the symbolic interactionist perspective. Results We identified four themes representing actual interactional communication and its 'meaning' or interpretation. The interactional communication in feedback is described in the first and second themes, such as 1) Students play the subordinate roles in a feedback dialogue; 2) The feedback content is focused on explanation and students' limitations. The third and fourth themes represent the clinical supervisors' and students' interpretation of their feedback experience, such as 3) Clinical supervisors' perspectives are mostly on dissatisfaction and teaching authority; 4) Students' acceptance of reality and negative affection. Conclusions This study shows that the social gap between students and clinical supervisors in Indonesia, and other countries in the same cultural classification, potentially causes communication barriers in the feedback dialogue. The adaptation of 'feedback as a dialogue' requires further effort and research to develop communication strategies in feedback that consider the national culture and context.
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Affiliation(s)
- Sylvia Mustika Sari
- Department of Medical Education and Bioethics, Faculty of Medicine, Jenderal Achmad Yani University Indonesia
- Department of Medical Education and Bioethics, Faculty of Medicine, Public health, and Nursing, Universitas Gadjah Mada, Indonesia
| | - Yoyo Suhoyo
- Department of Medical Education and Bioethics, Faculty of Medicine, Public health, and Nursing, Universitas Gadjah Mada, Indonesia
| | - Deddy Mulyana
- Department of Journalism, Faculty of Communication Sciences, Universitas Padjadjaran, Indonesia
| | - Mora Claramita
- Department of Medical Education and Bioethics, Faculty of Medicine, Public health, and Nursing, Universitas Gadjah Mada, Indonesia
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Wu JC, Tang KP, Hsu YHE, Yang YT, Chu JS, Lin YK, Hou WH. Medical undergraduates' self-evaluation: before and after curriculum reform. BMC MEDICAL EDUCATION 2022; 22:296. [PMID: 35443681 PMCID: PMC9019532 DOI: 10.1186/s12909-022-03330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/25/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In 2013, Taiwan launched a curriculum reform-the 7-year undergraduate medical education program was shortened to 6 years. This study explored the evaluation results from students regarding the curriculum reform and investigated graduates' perceptions regarding the curriculum organization of the two academic training programs affected by this curricular reform. METHODS A cross-sectional survey was conducted from May 14 to June 12, 2019. The 315 graduates from both the 7-year and 6-year curriculum programs in the same medical school in Taipei were invited to participate in this study. In total, 197 completed questionnaires were received, representing a response rate of 62.5%. The results of the principal component analysis confirmed the validity of the constructs employed in this self-administered questionnaire. RESULTS The t-test results yielded two main findings. First, the graduates from the 6-year program had significantly lower scores for preparedness for the upcoming postgraduate-year residency training than did their 7-year program counterparts. Additionally, the male graduates had significantly higher scores in terms of perceptions regarding curriculum organization and preparedness for postgraduate-year residency training than the female graduates. The results of stepwise regression also indicated that the sex difference was significantly correlated with graduates' readiness for their postgraduate-year residency training. CONCLUSION To avoid sex disparities in career development, a further investigation of female medical students' learning environment and conditions is necessary. In addition to the cross-sectional study of students' perceptions, further repeated measurements of the objective academic or clinical performance of graduates in clinical settings are desirable.
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Affiliation(s)
- Jeng-Cheng Wu
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, Taipei, Taiwan
| | - Kung-Pei Tang
- National Taipei University of Education, Taipei, Taiwan
| | - Yi-Hsin Elsa Hsu
- International Ph.D. Program in Biotech and Healthcare Management, Taipei Medical University, Taipei, Taiwan
| | - Ya-Ting Yang
- Center for General Education, Taipei Medical University, Taipei, Taiwan
| | - Jan-Show Chu
- School of Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031, Taiwan.
| | - Yen-Kuang Lin
- Graduate Institute of Athletics and Coaching Science, National Taiwan Sport University, Taoyuan, Taiwan.
- Biostatistics Research Center, Taipei Medical University, Taipei, Taiwan.
| | - Wen-Hsuan Hou
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan.
- Department of Geriatrics and Gerontology, Taipei Medical University Hospital, Taipei, Taiwan.
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Rietmeijer CBT, Deves M, van Esch SCM, van der Horst HE, Blankenstein AH, Veen M, Scheele F, Teunissen PW. A phenomenological investigation of patients' experiences during direct observation in residency: busting the myth of the fly on the wall. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:1191-1206. [PMID: 33765197 PMCID: PMC8452584 DOI: 10.1007/s10459-021-10044-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 03/07/2021] [Indexed: 05/30/2023]
Abstract
Direct observation (DO) of residents by supervisors is a highly recommended educational tool in postgraduate medical education, yet its uptake is poor. Residents and supervisors report various reasons for not engaging in DO. Some of these relate to their interaction with patients during DO. We do not know the patient perspectives on these interactions, nor, more broadly, what it is like to be a patient in a DO situation. Understanding the patient perspective may lead to a more complete understanding of the dynamics in DO situations, which may benefit patient wellbeing and improve the use of DO as an educational tool. We conducted a phenomenological interview study to investigate the experience of being a patient in a DO situation. Our analysis included multiple rounds of coding and identifying themes, and a final phase of phenomenological reduction to arrive at the essential elements of the experience. Constant reflexivity was at the heart of this process. Our results provide a new perspective on the role of the supervisor in DO situations. Patients were willing to address the resident, but sought moments of contact with, and some participation by, the supervisor. Consequently, conceptions of DO in which the supervisor thinks she is a fly on the wall rather than a part of the interaction, should be critically reviewed. To that end, we propose the concept of participative direct observation in workplace learning, which also acknowledges the observer's role as participant. Embracing this concept may benefit both patients' wellbeing and residents' learning.
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Affiliation(s)
- Chris B T Rietmeijer
- Department of General Practice/Family Medicine, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1109, 1081 HV, Amsterdam, The Netherlands.
- , Heemraadschapslaan 33, 1181 TZ, Amstelveen, The Netherlands.
| | - Mark Deves
- Department of General Practice/Family Medicine, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1109, 1081 HV, Amsterdam, The Netherlands
| | - Suzanne C M van Esch
- Department of General Practice/Family Medicine, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice/Family Medicine, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1109, 1081 HV, Amsterdam, The Netherlands
| | - Annette H Blankenstein
- Department of General Practice/Family Medicine, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1109, 1081 HV, Amsterdam, The Netherlands
| | - Mario Veen
- Department of General Practice, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rtterdam, The Netherlands
| | - Fedde Scheele
- Amsterdam University Medical Centers, School of Medical Sciences, Athena Institute for Transdisciplinary Research, VU University, location VUmc, Amsterdam, The Netherlands
| | - Pim W Teunissen
- School of Health Professions Education, Maastricht University, Universiteitssingel 60, 6229 ER, Maastricht, The Netherlands
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Rietmeijer CBT, Blankenstein AH, Huisman D, van der Horst HE, Kramer AWM, de Vries H, Scheele F, Teunissen PW. What happens under the flag of direct observation, and how that matters: A qualitative study in general practice residency. MEDICAL TEACHER 2021; 43:937-944. [PMID: 33765396 DOI: 10.1080/0142159x.2021.1898572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION In competency-based medical education, direct observation (DO) of residents' skills is scarce, notwithstanding its undisputed importance for credible feedback and assessment. A growing body of research is investigating this discrepancy. Strikingly, in this research, DO as a concrete educational activity tends to remain vague. In this study, we concretised DO of technical skills in postgraduate longitudinal training relationships. METHODS Informed by constructivist grounded theory, we performed a focus group study among general practice residents. We asked residents about their experiences with different manifestations of DO of technical skills. A framework describing different DO patterns with their varied impact on learning and the training relationship was constructed and refined until theoretical sufficiency was reached. RESULTS The dominant DO pattern was ad hoc, one-way DO. Importantly, in this pattern, various unpredictable, and sometimes unwanted, scenarios could occur. Residents hesitated to discuss unwanted scenarios with their supervisors, sometimes instead refraining from future requests for DO or even for help. Planned bi-directional DO sessions, though seldom practiced, contributed much to collaborative learning in a psychologically safe training relationship. DISCUSSION AND CONCLUSION Patterns matter in DO. Residents and supervisors should be made aware of this and educated in maintaining an open dialogue on how to use DO for the benefit of learning and the training relationship.
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Affiliation(s)
- Chris B T Rietmeijer
- Department of General Practice, Location VUmc, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Annette H Blankenstein
- Department of General Practice, Location VUmc, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Daniëlle Huisman
- Department of General Practice, Location VUmc, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice, Location VUmc, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Anneke W M Kramer
- Department of Public Health and Primary Care, Leiden University, Leiden, The Netherlands
| | - Henk de Vries
- Department of General Practice, Location VUmc, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fedde Scheele
- School of Medical Sciences, Amsterdam University Medical Center, Location VUmc, Athena Institute for Transdisciplinary Research, VU University, Amsterdam, The Netherlands
| | - Pim W Teunissen
- School of Health Professions Education, Maastricht University, Universiteitssingel 60, Maastricht, The Netherlands
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Bredmose PP, Røislien J, Østergaard D, Sollid S. National Implementation of In Situ Simulation-Based Training in Helicopter Emergency Medical Services: A Multicenter Study. Air Med J 2021; 40:205-210. [PMID: 34172225 DOI: 10.1016/j.amj.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Medical simulation is used in helicopter emergency services as a tool for training the crew. Using in situ simulation, we aimed to evaluate the degree of implementation, the barriers to completing simulation training, and the crew's attitude toward this form of training. METHODS This was a 1-year prospective study on simulation at all 14 Norwegian helicopter emergency services bases and 1 search and rescue base. Local facilitators were educated and conducted simulations at their discretion. RESULTS All bases agreed to participate initially, but 1 opted out because of technical difficulties. The number of simulations attempted at each base ranged from 1 to 46 (median = 17). Regardless of the base and the number of attempted simulations, participating crews scored self-evaluated satisfaction with this form of training highly. Having 2 local facilitators increased the number of attempted simulations, whereas facilitators' travel distance to work seemed to make no difference on the number of attempted simulations. CONCLUSION Our study reveals considerable differences in the number of attempted simulations between bases despite being given the same prerequisites. The busiest bases completed fewer simulations than the rest of the bases. Our findings suggest that conditions related to the local facilitator are important for the successful implementation of simulation-based training in helicopter emergency services.
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Affiliation(s)
- Per P Bredmose
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Air Ambulance Department, Oslo University Hospital, Oslo, Norway; Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - Jo Røislien
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Doris Østergaard
- Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark and University of Copenhagen, Copenhagen, Denmark
| | - Stephen Sollid
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Mourik SL, Roos EJ, Goverde AJ, Wood PL. The new pan-European post-specialty training curriculum in Paediatric and Adolescent Gynaecology. Eur J Obstet Gynecol Reprod Biol 2020; 258:152-156. [PMID: 33422776 DOI: 10.1016/j.ejogrb.2020.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/29/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Interest in the field of Paediatric and Adolescent Gynaecology (PAG) has increased substantially over the last decade. Currently there is minimal consensus on how to interpret and validate professional experience, medical knowledge and surgical skills for doctors (accredited in Obstetrics and Gynaecology) who have an interest in and wish to achieve sub-specialisation in PAG. The challenge for the future of PAG is to create a framework of guidelines and references which in turn culminates in improvement and harmonisation in PAG healthcare delivery. The development of a post-specialty training curriculum in PAG for accredited practitioners was a logical next step after EBCOG introduced the PACT curriculum for OBGYN trainees. The guiding principle in the development of the PAG curriculum has been to strive for harmonisation in teaching and training in PAG within Europe. The new EURAPAG curriculum is divided in 17 chapters which in turn have been subdivided into medical and surgical sections plus a baseline skills section. The content has been determined through a consensus procedure amongst European gynaecologists and trainees. The medical chapters involve pathology that requires conservative treatment, prevention, education or lifestyle adjustment. The chapters that are both medical and surgical have a surgical (alternative) treatment ranging from vaginal procedures to advanced hysteroscopic and laparoscopic procedures and laparotomy. Currently, the framework for any medical education is workplace based competency training. Specific tools have been developed for workplace based assessments, such as direct observation (DO) of clinical task performance, Objective Structured Assessment of Technical Skills (OSATS), mini-clinical evaluation exercise (Mini-CEX) or case-based discussion (CBD). To measure progress in this PAG post-specialty training curriculum, the subspecialty trainee will be required to maintain and update a portfolio of experience and competency.
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Affiliation(s)
- Sarah L Mourik
- London Women's Clinic, 113-115 Harley Street, W1G 6AP, London, United Kingdom.
| | - Eveline J Roos
- Tergooi, Department Obstetrics and Gynaecology, van Riebeeckweg 212, 1213 XZ, Hilversum, the Netherlands.
| | - Angelique J Goverde
- UMC Utrecht, Department of Reproductive Medicine and Gynaecology, Heidelberglaan 100, 3508 GA, Utrecht, the Netherlands.
| | - Paul L Wood
- Addenbrooke's Hospital, Cambridge Biomedical Campus, Hill Road, Cambridge, CB2 0QQ, United Kingdom.
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