Exploring formal and informal learning opportunities during morning report: a qualitative study.

BACKGROUND: Morning reports are an essential component of physicians' daily work. Attending morning reports is prioritized by junior doctors as it provides them with an opportunity to learn diagnostic reasoning through discussion of cases. While teaching formats during morning reports have previously been reported, an in-depth analysis of what learning opportunities exist, e.g., how teaching is enacted during morning reports, is lacking. This qualitative study explores learning opportunities during morning reports. METHODS: We used an explorative design based on video-recordings of 23 morning reports from two surgical departments, an internal medicine department and an emergency department. We used thematic analysis combined with and inspired by Eraut's theoretical framework of workplace learning. RESULTS: Both formal and informal learning opportunities were identified. Formal learning opportunities had the character of planned teaching activities, and we identified four themes: (1) modes of teaching, (2) structure, (3) presenter role, and (4) participant involvement. Informal learning, on the other hand, was often implicit and reactive, while deliberate learning opportunities were rare. The data showed many missed opportunities for learning. CONCLUSION: Both formal and informal learning opportunities are present during morning reports. However, a prevalent focus on medical topics exists, leaving other important aspects of the medical role under-discussed. Pedagogical methods could be employed more optimally, and harnessing the potential of missed opportunities should be encouraged.

Multi-source feedback reinforces junior doctors' awareness of the need to achieve and train clinical leadership.

INTRODUCTION: Increasing complexity in healthcare makes it necessary to strengthen leadership training in postgraduate medical education (PGME). Multi-source feedback (MSF) is an acknowledged formative assessment method widely implemented in PGME. The present study examined how MSF may support junior doctors' awareness of the need to achieve and train leadership skills in clinical practice. METHODS: Semi-structured interviews were conducted with 30 junior doctors late in PGME after they had completed a leadership-focused MSF process. Written personal development plans were collected. Data were analysed using thematic analysis. RESULTS: The majority of the junior doctors found that the MSF process was intense, rewarding and helpful for understanding the many facets of clinical leadership. The personal feedback dialogue and the development plan were highlighted as the most beneficial elements of the process. The MSF process identified new learning objectives for leadership development such as task delegation, independent decision-making, becoming a role model and giving and seeking feedback. CONCLUSIONS: Junior doctors found that a leadership-focused MSF process increased their attention to and awareness of leadership in daily clinical practice and provided deep insights into and specific tools to develop leadership skills. Thus, a leadership-focused MSF process may contribute to and increase junior doctors' leadership skills. FUNDING: The study was supported financially by the Central and North Denmark Region. TRIAL REGISTRATION: Registered with the Central Denmark Region: 1-16-02-315-20.

How doctors build community and socialize into a clinical department through morning reports. A positioning theory study.

PHENOMENON: The morning report is one of the longest surviving hospital practices. Most studies of the morning report focus on the effectiveness of formal medical training, while focus on social and communicative aspects is rarer. This study explores the social interactions and communication in morning reports, examining the ways in which they contribute to the construction of professional identity and socialization into the community of the clinical department. APPROACH: We used a qualitative explorative design with video observations of morning reports. Our data consisted of 43 video-recorded observations (in all, 15.5 hours) from four different hospital departments in Denmark. These were analyzed using the theoretical framework of positioning theory. FINDINGS: A key finding was that each department followed its own individual structure. This order was not articulated as such but played out implictly. Two alternative storylines unfolded in the elements of the morning report: 1) being equal members of the specialty and department, and 2) preserving the hierarchical community and its inherent positions. INSIGHTS: The morning report can be seen as playing an important role in community making. It unfolds as a "dance" of repeated elements in a complex collegial space. Within this complexity, the morning report is a space for positioning oneself and others as a collegial "we", i.e., equal members of a department and specialty, at the same time as "having a place" in a hierarchal community. Thus, morning reports contribute to developing professional identity and socialization into the medical community.

What works in appraisal meetings for newly graduated doctors? - and what doesn't?

BACKGROUND: In Denmark a national formal advisory program (NFAP) is mandatory in Postgraduate Medical Education (PGME). According to this, an educational advisor is assigned to each doctor in every clinical rotation to guide and oversee the work and learning progress of the trainee. This study explores why newly graduated trainees evaluated the appraisal meetings in the advisory program as either beneficial (successes) or not beneficial (non-successes). METHODS: Inspired by the Success Case Method, a survey was conducted among all 129 doctors employed in their first six-month clinical rotation of postgraduate medical education (PGY1) in the Central Denmark Region. A cluster analysis resulted in a group with eight successes respectively seven non-successes. Semi-structured interviews were conducted with six successes and five non-successes. RESULTS: In contrast to non-successes, the successes had longer appraisal meetings and their advisor introduced them to purpose and process of meetings including use of the personal learning plan. Successes received feedback on clinical skills, overall global performance and career plans. The successes perceived their advisors as prepared, skilled and motivated and the advisor acted as a contact person. To the successes, the appraisal meetings fostered clarification of and reflections on educational goals, progress and career as well as self-confidence and a sense of security. CONCLUSION: Success with appraisal meetings seemed to depend on advisor's skills and motivation including willingness to prioritize time for this task. The results from this study indicate the importance of faculty development. It also raises the question if all doctors should serve as advisors or if this task should be assigned to the most motivated candidates.

The Danish Choosing Wisely concept.

Introduction Choosing Wisely has been introduced in more than 20 countries. In Denmark, the Vælg Klogt initiative was launched in the spring of 2020. The aim of Vælg Klogt is to reduce unnecessary and potentially harmful tests, treatments and procedures in healthcare. Vælg Klogt also contributes to the implementation of shared decision-making. This study explored knowledge of the Danish Vælg Klogt initiative among patient associations and scientific societies in Denmark. Methods This was a cross-sectional questionnaire study among patient associations and scientific societies. Descriptive and content analyses were used to interpret the quantitative and qualitative results, respectively. Results Both the patient associations and the scientific societies had little knowledge of Vælg Klogt; still, they agreed that overuse and waste occurs in Danish healthcare. The reasons are multifactorial, but both parties mentioned a fear of making mistakes and a lack of communication between departments. The initiative is welcomed, provided recommendations are based on evidence, integrated into clinical guidelines, well communicated and prepared in collaboration between patients and physicians. Conclusions Knowledge of the Danish Vælg Klogt initiative is scarce and implementation of Vælg Klogt must include extensive communication to patients, physicians, leaders and politicians. However, the mutual agreement between patient associations and scientific societies on the reasons for overuse promises well for the initiative. Funding none Trial registration Registered in the Central Denmark Region: 1-16-02-553-20.

Transfer of communication teaching skills from university to the clinical workplace - does it happen? A mixed methods study.

BACKGROUND: Communication skills learned in the classroom do not transfer easily into clinical practice because they are not reinforced by teachers in the workplace setting and because lack of faculty training restricts the transfer of communication skills in real patient encounters. Trained university-based communication skills teachers often work simultaneously as doctors in clinics. This study explored if and how the skills of these teachers play a role in communication skills training in the clinical workplace. METHODS: We used an exploratory sequential design: a mixed method approach that combined a survey with communication skills teachers, and qualitative individual interviews with these teachers and their educational leaders in clinical departments. The questionnaire was analysed using descriptive statistics. The interviews were analysed using content analysis. RESULTS: The response rate was 34 %. A majority (93 %) used their communication skills when communicating with patients and relatives. Less than half taught communication in clinical departments. Approximately half of the respondents stated that encouragement from their leaders or colleagues would inspire them to use their teaching skills in the workplace. However, only 20 % had told their leaders about their competencies in teaching communication. One third thought that they needed further teacher training to teach in the clinical workplace. Qualitative analysis showed that teaching opportunities existed but mainly consisted of random, one-off sessions that came about through the initiative of the communication skills teachers themselves. The teachers described several barriers, such as the challenge of teaching colleagues, as communication relates to identity and hierarchical structures, as well as a lack of requests from colleagues or management, and department culture prioritizing topics relating to medical expertise. None of the educational leaders made use of the teachers' specific communication skills in a structured way: some saw it as unimportant, while others saw it as a potential resource. CONCLUSION: Transfer of the teaching skills of communication skills teachers trained for university-based clinical communication training happened, but to a limited degree. Although both opportunities and barriers for transferring communication skills existed, barriers seemed to dominate, and opportunities for communication skills training in the workplace setting were not used to their full potential.

Can case-based discussions in a group setting be used to assess residents' clinical skills?

OBJECTIVES: The purpose of this study was to explore residents' and assessors' perception of a new group assessment concept. METHODS: This qualitative study consists of observations of four group assessment sessions, followed by semi-structured interviews with six residents and four assessors (specialists in internal medicine), who all volunteered to be interviewed. All residents at a medical department (eleven to fifteen each time) and four assessors participated in four group assessments, where the residents' clinical skills were assessed through case-based discussions. An external consultant (an anthropologist) performed the observations and the interviews. Notes from the observations and the interviews were analyzed using an inductive approach. RESULTS: Eight of the ten interviewed participants preferred group assessment to individual assessment. Results from the interviews suggested that the group assessments were more consistent and that the level of discussion was perceived to be higher in the group discussions compared to the one-to-one discussions. All residents indicated that they had acquired new knowledge during their assessment and reported having learned from listening to the assessment of their peers. Assessors similarly reported gaining new knowledge. CONCLUSIONS: The residents and assessors expressed very favourable attitudes toward the new group assessment concept. The assessment process was perceived to be higher in quality and more consistent, contributing to learning for all participating doctors in the department. Group assessment is feasible and acceptable, and provides a promising tool for assessment of clinical skills in the future.

How group coaching contributes to organisational understanding among newly graduated doctors.

BACKGROUND: Practising medicine at an expert level requires skills beyond medical expert knowledge. Research shows that newly appointed consultants feel less prepared to deal with leadership issues compared to issues regarding medical expertice. Newly graduated (NG) doctors and residents in particular struggle with leadership and organisational issues. The purpose of this study was to explore the impact of group coaching on NG doctors' approach to organisational and leadership challenges in daily practice during the transition period from medical school to clinical work. METHODS: Newly graduated doctors participated in a group coaching course comprising three full-day sessions and five two-hour sessions. The purpose was to support NG doctors' professional development regarding organisational issues in the first years after graduation. The coaches were health professionals with certified coaching training. Data from the intervention were collected from open-ended questionnaires and observational notes. A thematic analysis was performed. RESULTS: Forty-five NG doctors participated in a total of six courses sharing experiences and problems reflected in their professional lives. The following themes emerged: Revelation of the hidden curriculum, importance of professional relations, inter-professional communication, conflict management and emerging leadership skills. Participants' communication skills improved due to an increased awareness of other peoples' perspectives and preferences. They realized the importance of good relations, saw how they could become active contributors in their departments and began to practice leadership skills through e.g. involvement of the team, delegation of work and negotiation of own obligations. CONCLUSION: Newly graduated doctors seemed to develop a growing awareness of organisational issues and a deeper understanding of the complexity of health care organisations through participation in a group coaching course. The study indicates that participation in a group coaching course probably contributes to improve practice among NG doctors. Further studies are needed to consolidate the findings and explore possible organisational effects.

How are formative assessment methods used in the clinical setting? A qualitative study.

OBJECTIVES: To explore how formative assessment methods are used and perceived by second-year junior doctors in different clinical settings. METHODS: A focused ethnography study was carried out. Ten second-year junior doctors from different specialties were selected using purposive sampling. The junior doctors were observed during a day in their clinical workplace where formative assessment was in focus. They were subsequently phone interviewed using a semi-structured interview guide regarding their experiences and attitudes towards formative assessment. Field notes from observations and interview transcriptions were analyzed using an inductive content analysis approach, and the concept of "everyday resistance" was used as a theoretical lens. RESULTS: Three themes were identified: First, there were several barriers to the use of formative assessment methods in the clinical context, including subtle tactics of everyday resistance such as avoidance, deprioritizing, and contesting formative assessment methods.  Secondly, junior doctors made careful selections when arranging a formative assessment. Finally, junior doctors had ambiguous attitudes towards the use of mandatory formative assessment methods and mixed experiences with their educational impact. CONCLUSIONS: This study emphasizes that the use of formative assessment methods in the clinical setting is not a neutral and context-independent exercise, but rather is affected by a myriad of factors such as collegial relations, educational traditions, emotional issues, and subtle forms of resistance. An important implication for the health care sector will be to address these issues for formative assessment methods to be properly implemented in the clinic.

Implementation of workplace-based assessment in general practice.

Background: Workplace-based assessment (WPBA) is widely accepted, but few studies have investigated implementation issues during general practice (GP) placements. This study explored possible barriers and identified key elements for successful implementation of a WPBA-programme in Danish GP specialist training. Methods: Supervisors had attended a one-day course in WPBA and trainees had received a short introduction. Questionnaires on experiences with implementation of WPBA were distributed to 106 GP supervisors and 110 trainees after the rotation was finished. Results: The response rate was 61/96 (64%) for trainees and 67/94 (71%) for supervisors. Supervisors were generally more positive towards WPBA and saw fewer barriers than trainees. Lack of planning was most often reported as an impediment to WPBA. Supervisors did not identify trainees' uneasiness of being observed as a problem as often as trainees. A total of 34% of trainees reported uneasiness as an obstacle to WPBA. Conclusions: It seems that the education of supervisors positively influenced supervisors' perception and use of WPBA. Adequate planning of WPBA may be just as big a problem as assigning the time. Further investigations on the impact of education on trainees' perception of WPBA are needed.

Workplace-based communication skills training in clinical departments: Examining the role of collegial relations through positioning theory.

INTRODUCTION: Studies suggest that the workplace is a key to understanding how clinical communication skills learning takes place and that medical communication skills need to be reinforced over time in order not to deteriorate. This study explored the perceptions of doctors in four hospital departments who participated in a workplace-based communication training project. Its specific focus was the relationship between collegial relations and learning communication skills. METHODS: The study applied a qualitative design using an ethnographic methodology, i.e. interviews and observations. Positioning theory was used as the theoretical framework. RESULTS: Training communication skills with colleagues in the actual workplace setting was valued by the participants who experienced more sharing of communication challenges, previously understood as something private one would not share with colleagues. However, collegial relations were also barriers for providing critical feedback, especially from junior doctors to their seniors. CONCLUSION: The position as "colleague" both reinforced the communication skills training and hindered it. The communication skills educational model had a flat, non-hierarchical structure which disturbed the hierarchical structure of the workplace, and its related positions.

A SWOT analysis of how the youngest doctors perceive the formal Danish educational advisory programme.

INTRODUCTION: A national formal advisory programme (NFAP) was introduced in Denmark in 1998. This study investigates the implementation of the NFAP and identifies areas to improve. METHODS: In March 2017, a survey was conducted among all 129 doctors employed in the first rotation of postgraduate medical education in the Central Denmark Region. A priority chart was created to appoint strengths, weaknesses, op-portunities and threats (SWOT). RESULTS: The response rate was 67%. The questionnaire showed good reliability and discriminant validity. Almost all respondents had completed the recommended appraisal meetings and a personal learning plan, both of which - in contrast to the NFAP's coherence to everyday clinical practice - showed to have much influence on the overall value of the NFAP. Strengths found were that appraisal meetings and learning plans support the development of clinical competencies, the latter identifying learning objectives and how to achieve them. Threats identified included learning plans that were not prepared sufficiently early, were not regularly adjusted and that did not describe when each learning objective is to be achieved, or when, by whom or how assessment will take place. CONCLUSIONS: Appraisal meetings and learning plans seem to be well implemented and to support the development of clinical competencies. Even so, improvements are needed, particularly to ensure an earlier preparation, inclusion of plans for assessment and regular adjustment of the learning plans. FUNDING: The study was funded by the Central Denmark Region. TRIAL REGISTRATION: Data collection was approved by the Danish Health Data Authority.

Redesign of the System for Evaluation of Teaching Qualities in Anesthesiology Residency Training (SETQ Smart).

BACKGROUND: Given the increasing international recognition of clinical teaching as a competency and regulation of residency training, evaluation of anesthesiology faculty teaching is needed. The System for Evaluating Teaching Qualities (SETQ) Smart questionnaires were developed for assessing teaching performance of faculty in residency training programs in different countries. This study investigated (1) the structure, (2) the psychometric qualities of the new tools, and (3) the number of residents' evaluations needed per anesthesiology faculty to use the instruments reliably. METHODS: Two SETQ Smart questionnaires-for faculty self-evaluation and for resident evaluation of faculty-were developed. A multicenter survey was conducted among 399 anesthesiology faculty and 430 residents in six countries. Statistical analyses included exploratory factor analysis, reliability analysis using Cronbach α, item-total scale correlations, interscale correlations, comparison of composite scales to global ratings, and generalizability analysis to assess residents' evaluations needed per faculty. RESULTS: In total, 240 residents completed 1,622 evaluations of 247 faculty. The SETQ Smart questionnaires revealed six teaching qualities consisting of 25 items. Cronbach α's were very high (greater than 0.95) for the overall SETQ Smart questionnaires and high (greater than 0.80) for the separate teaching qualities. Interscale correlations were all within the acceptable range of moderate correlation. Overall, questionnaire and scale scores correlated moderately to highly with the global ratings. For reliable feedback to individual faculty, three to five resident evaluations are needed. CONCLUSIONS: The first internationally piloted questionnaires for evaluating individual anesthesiology faculty teaching performance can be reliably, validly, and feasibly used for formative purposes in residency training.

Professional identity formation in the transition from medical school to working life: a qualitative study of group-coaching courses for junior doctors.

BACKGROUND: The transition from student to medical doctor is challenging and stressful to many junior doctors. To practice with confidence and professionalism the junior doctors have to develop a strong professional identity. Various suggestions on how to facilitate formation of professional identity have been offered including the possible positive effect of group-coaching courses. The purpose of this study was to explore how group-coaching might facilitate professional identity formation among junior doctors in the transition period. METHODS: Group-coaching courses comprising three whole-day sessions and five 2 h sessions during a period of 4 months were offered to junior doctors in the first years after graduation. The purpose was to support the participants' professional development, ability to relate to patients, relatives and staff and career development. The coaches in this study had a background as health professionals combined with coaching educations. Data was obtained through observations, open-ended questionnaires and interviews. A generic thematic analysis was applied. RESULTS: Forty-five doctors participated in six coaching groups. The three main themes emerging in the sessions were: Adoption to medical culture, career planning, and work/life-balance. The junior doctors found the coaching intervention highly useful in order to cope with these challenges. Furthermore, the group was a forum where the junior doctors could share thoughts and feelings with colleagues without being afraid that this would endanger their professional career. Many found new ways to respond to everyday challenges mainly through a new awareness of patterns of thinking and feeling. CONCLUSIONS: The participants found that the group-coaching course supported their professional identity formation (thinking, feeling and acting as a doctor), adoption to medical culture, career planning and managing a healthy work/life-balance. Further studies in different contexts are recommended as well as studies using other methods to test the results of this qualitative study.

[A model for multi-source feedback in postgraduate medical education based on validation and best practise].

In Denmark multi-source feedback is used in formative assessment of trainees' performance regarding the roles: communicator, collaborator, professional and manager. A web-based model was developed and evaluated useful, time-effective, acceptable and feasible. The model comprises a validated questionnaire usable in all specialities, personal feedback from an educated feedback facilitator, identification of areas for improvement and a mandatory written plan for the trainees' further professional development. The model is implemented at all hospitals in the Northern Educational Region in Denmark.

[The use of reflection as an educational tool is important to render professional competence]. / Refleksion som læringsmetode i den professionelle rolle er vigtig.

Professionalism can be difficult to teach and integrate in the clinical training of younger doctors. Making the professional competences visible in an educational context is a challenge for most clinical educators. This paper presents the use of reflection as an educational tool, where the use of narratives, literature and focused dialogues with a supervisor are relevant methods. These approaches make it possible to render the professional competences concrete and tangible in the supervision of professional identity development as well as in the ways of being a doctor.

[A group coaching course supports professional development of doctors under specialist training].

A group coaching course for doctors under specialist training was evaluated. The course consisted of group coaching, theoretical presentations and practical exercises over a three-month period. The confidential forum of colleagues was of utmost importance, creating recognition and social support in contrast to the collegiate competitiveness of the workplace. The doctors found new ways of dealing with professional problems and acquired new communication skills. Further investigations are needed to decide whether group coaching should be offered to all trainees.