Thresholds of becoming: an exploration of threshold concepts as a means to support professional identity formation in competency-based curricula.

Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training.

Goal co-construction and dialogue in an internal medicine longitudinal coaching programme.

BACKGROUND: Longitudinal coaching in residency programmes is becoming commonplace and requires iterative and collaborative discussions between coach and resident, with the shared development of goals. However, little is known about how goal development unfolds within coaching conversations over time and the effects these conversations have. We therefore built on current coaching theory by analysing goal development dialogues within resident and faculty coaching relationships. METHODS: This was a qualitative study using interpretive description methodology. Eight internal medicine coach-resident dyads consented to audiotaping coaching meetings over a 1-year period. Transcripts from meetings and individual exit interviews were analysed thematically using goal co-construction as a sensitising concept. RESULTS: Two themes were developed: (i) The content of goals discussed in coaching meetings focused on how to be a resident, with little discussion around challenges in direct patient care, and (ii) co-construction mainly occurred in how to meet goals, rather than in prioritising goals or co-constructing new goals. CONCLUSIONS: In analysing goal development in the coach-resident relationships, conversations focused mainly around how to manage as a resident rather than how to improve direct patient care. This may be because academic coaching provides space separate from clinical work to focus on the stage-specific professional identity development of a resident. Going forward, focus should be on how to optimise longitudinal coaching conversations to ensure co-regulation and reflection on both clinical competencies and professional identity formation.

Patient-present teaching in the clinic: Effect on agency and professional behaviour.

BACKGROUND/PURPOSE: Although much has been written about the medical learning environment, the patient, who is the focus of care, is rarely the focus in this literature. The purpose of this study was to explore the role of the patient as an active participant with agency in the medical learning environment from the standpoint of the learner, the attending physician, and most importantly, the patient. We hoped to gain insights into the mechanisms that can reinforce professional values such as patient-centred and respectful behaviours in a patient-present learning environment. METHODS: We conducted this study in an ambulatory internal medicine clinic using 'patient-present' clinic visits. All case presentations occurred in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semistructured interviews after each clinic visit to explore the impact of the patient-present learning environment. We recruited 34 participants in the study; 10 attending physicians, 12 learners, 10 patients and 2 family members. We analysed the data deductively using a conceptual framework of agency. SUMMARY/RESULTS: We identified three major insights: (1) Patients felt engaged and valued opportunities to be heard; (2) Attending physicians and learners reported a more respectful learning environment and a positive though challenging teaching and learning experience; and (3) A hidden curriculum emerged in a performance-based view of professional behaviour. CONCLUSIONS: Patient-present teaching engaged patients and enhanced their agency by recasting the patient as the central focus within the healthcare encounter. We identified a tension between performing and learning. This study adds new insights to the concept of patient centredness and professionalism from the perspectives of all participants in the medical teaching and learning environment.

Presenting cases in front of patients: implications for a key medical education genre.

Case presentations have been researched as both an important form of intra/inter-professional communication, where a patient's clinical information is shared among health professionals involved in their care, and an equally key discursive tool in education, where learners independently assess a patient and present the case to their preceptor and/or care team. But what happens to the case presentation, a genre that governs physician (and learner) talk about patients, when it is used in patients' presence? While they were commonly used at the bedside in the past, case presentations today are more commonly performed in hallways or conference rooms, out of patient earshot. This paper draws on interview data from a study involving patient-present case presentations in a medical education setting. Our analysis asks what participants' metageneric comments about the encounter can teach us about the genre, about patient involvement in medical education, and about linguistic adaptations to the genre that the profession might make to support patient involvement.

Incentives for clinical teachers: On why their complex influences should lead us to proceed with caution.

INTRODUCTION: When medical education programs have difficulties recruiting or retaining clinical teachers, they often introduce incentives to help improve motivation. Previous research, however, has shown incentives can unfortunately have unintended consequences. When and why that is the case in the context of incentivizing clinical teachers remains unclear. The purposes of this study, therefore, were to understand what values and motivations influence teaching decisions; and to delve deeper into how teaching incentives have been perceived. METHODS: An interpretive description methodology was used to improve understanding of the development and delivery of teaching incentives. A purposeful sampling strategy identified a heterogenous sample of clinical faculty teaching in undergraduate and postgraduate contexts. Sixteen semi-structured interviews were conducted and transcripts were analyzed using an iterative process to develop a thematic structure that accounts for general trends and individual variations. RESULTS: Clinicians articulated interrelated and dynamic personal and environmental factors that had linear, dual-edged and inverted U-shaped impacts on their motivations towards teaching. Barriers were frequently rationalized away, but cumulative barriers often led to teaching attrition. Clinical teachers were motivated when they felt valued and connected to their learners, peers, leadership, and/or the medical education community. While incentives aimed at producing these connections could be perceived as supportive, they could also negatively impact motivation if they were impersonal, inequitable, inefficient, or poorly framed. DISCUSSION/CONCLUSION: These findings reinforce the literature suggesting that it is necessary to proceed with caution when labeling any particular factor as a motivator or barrier to teaching. They take us deeper, however, towards understanding how and why clinical teachers' perceptions are unique, dynamic and fluid. Incentive schemes can be beneficial for teacher recruitment and retention, but must be designed with nuance that takes into account what makes clinicians feel valued if the strategy is to do more good than harm.

Necessary but not sufficient: identifying conditions for effective feedback during internal medicine residents' clinical education.

Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents' and 7 faculty members' perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.

Investigating conditions for meaningful feedback in the context of an evidence-based feedback programme.

CONTEXT: We developed, implemented and evaluated an evidence-based programme of feedback designed to address limitations identified in the current literature. OBJECTIVES: We sought to advance understanding about how and why feedback processes might be more effective in clinical education. METHODS: Three faculty members and nine first-year internal medicine residents participated in the pilot programme. To counter challenges identified in the literature, feedback was based on direct observation, grounded in longitudinal faculty-resident relationships, and devoid of summative assessment. We used a qualitative case study design to address three research questions: (i) What benefits did the participants describe? (ii) What elements of the programme facilitated these benefits? (iii) What were the limitations and challenges of the programme? Collected data included audiotapes of interactions between faculty members and residents, field notes written during observations, and semi-structured interviews and focus groups with resident participants. Data analysis moved cyclically and iteratively through inductive and deductive analysis. RESULTS: Residents described benefits relating to their ways of working (clinical skills), ways of learning (accountability for learning) and ways of feeling (emotional well-being). According to participants, specific elements of the programme that achieved these benefits included the direct observation of authentic clinical work, the longitudinal relationship with a faculty member and the emergence of feedback as a conversation between the faculty member and learner. CONCLUSIONS: We conclude that the conditions established within our pilot feedback programme influenced the learning culture for first-year internal medicine residents by grounding direct observation in authentic clinical work and setting the observations in the context of a longitudinal, non-assessment-based relationship between a faculty member and resident. These conditions appeared to influence residents' participation in the feedback process, their ways of approaching their daily clinical work, their emotional well-being and their engagement in their own learning.

Upward Feedback: Exploring Learner Perspectives on Giving Feedback to their Teachers.

Introduction: Feedback from learners is known to be an important motivator for medical teachers, but it can be de-motivating if delivered poorly, leaving teachers frustrated and uncertain. Research has identified challenges learners face in providing upward feedback, but has not explored how challenges influence learners' goals and approaches to giving feedback. This study explored learner perspectives on providing feedback to teachers to advance understanding of how to optimize upward feedback quality. Methods: We conducted semi-structured interviews with 16 learners from the MD program at the University of British Columbia. Applying an interpretive description methodology, interviews continued until data sufficiency was achieved. Iterative analysis accounted for general trends across seniority, site of training, age and gender as well as individual variations. Findings: Learners articulated well-intentioned goals in relation to upward feedback (e.g., to encourage effective teaching practices). However, conflicting priorities such as protecting one's image created tensions leading to feedback that was discordant with teaching quality. Several factors, including the number of feedback requests learners face and whether learners think their feedback is meaningful mediated the extent to which upward feedback goals or competing goals were enacted. Discussion: Our findings offer a nuanced understanding of the complexities that influence learners' approaches to upward feedback when challenges arise. In particular, goal conflicts make it difficult for learners to contribute to teacher support through upward feedback. Efforts to encourage the quality of upward feedback should begin with reducing competition between goals by addressing factors that mediate goal prioritization.

Modification of an OSCE format to enhance patient continuity in a high-stakes assessment of clinical performance.

BACKGROUND: Traditional Objective Structured Clinical Examinations (OSCEs) are psychometrically sound but have the limitation of fragmenting complex clinical cases into brief stations. We describe a pilot study of a modified OSCE that attempts to balance a typical OSCE format with a semblance of a continuous, complex, patient case. METHODS: Two OSCE scenarios were developed. Each scenario involved a single standardized patient and was subdivided into three sequential 10 minute sections that assessed separate content areas and competencies. Twenty Canadian PGY-4 internal medicine trainees were assessed by trained examiner pairs during each OSCE scenario. Paired examiners rated participant performance independent of each other, on each section of each scenario using a validated global rating scale. Inter-rater reliabilities and Pearson correlations between ratings of the 3 sections of each scenario were calculated. A generalizability study was conducted. Participant and examiner satisfaction was surveyed. RESULTS: There was no main effect of section or scenario. Inter-rater reliability was acceptable. The g-coefficient was 0.68; four scenarios would achieve 0.80. Moderate correlations between sections of a scenario suggest a possible halo effect. The majority of examiners and participants felt that the modified OSCE provided a sense of patient continuity. CONCLUSIONS: The modified OSCE provides another approach to the assessment of clinical performance. It attempts to balance the advantages of a traditional OSCE with a sense of patient continuity.

It's all about relationships : A qualitative study of family physicians' teaching experiences in rural longitudinal clerkships.

INTRODUCTION: The relationship between preceptor and trainee is becoming recognized as a critical component of teaching, in particular in the negotiation of feedback and in the formation of professional identity. This paper elaborates on the nature of the relationships between preceptor and student that evolve in the context of rural longitudinal integrated clerkships (LICs). METHODS: We drew on constructivist grounded theory for the research approach. We interviewed nine LIC family practice preceptors from three sites at one educational institution. We adapted the interview framework based on early findings. We analyzed the data through a constant comparative process. We then drew on concepts of relationship-based learning as sensitizing concepts in a secondary analysis. RESULTS: We constructed three themes from the data. First, preceptors developed trusting professional and personal relationships with students over time. These relationships expanded to include friendship, advocacy, and ongoing contact beyond the clerkship year. Second, preceptors' approach to teaching was anchored in the relationship with an understanding of the individual student. Third, preceptors set learning goals collaboratively with their students, based not only on program objectives, but also with the student as a future physician in mind. DISCUSSION: Our findings suggest that rural family medicine preceptors developed engaged and trusting relationships with their students over time. These relationships imbued all activities of teaching and learning with an individual and personal focus. This orientation may be a key factor in supporting the learning outcomes demonstrated for students studying in rural LICs.