Practicing Confidence: An Autoethnographic Exploration of the First Years as Physicians.

Phenomenon: Every year is heralded with a cohort of newly-minted medical school graduates. Through intense residency training and supervision, these learners gradually develop self-assurance in their newfound skills and ways of practice. What remains unknown, however, is how this confidence develops and on what it is founded. This study sought to provide an insider view of this evolution from the frontline experiences of resident doctors. Approach: Using an analytic collaborative autoethnographic approach, two resident physicians (Internal Medicine; Pediatrics) documented 73 real-time stories on their emerging sense of confidence over their first two years of residency. A thematic analysis of narrative reflections was conducted iteratively in partnership with a staff physician and a medical education researcher, allowing for rich, multi-perspective input. Reflections were analyzed and coded thematically and the various perspectives on data interpretation were negotiated by consensus discussion. Findings: In the personal stories and experiences shared, we take you through our own journey and development of confidence, which we have come to appreciate as a layered and often non-linear process. Key moments include fears in the face of the unknown; the shame of failures (real or perceived); the bits of courage gained by everyday and mundane successes; and the emergence of our personal sense of growth and physicianship. Insights: Through this work, we - as two Canadian resident physicians - have ventured to describe a longitudinal trajectory of confidence from the ground up. Although we enter residency with the label of 'physician,' our clinical acumen remains in its infancy. We graduate from residency still as physicians, but decidedly different in terms of our knowledge, attitudes, and skills. We sought to capitalize on the vulnerability and authenticity inherent in autoethnography to enrich our collective understanding of confidence acquisition in the resident physician and its implications for the practice of medicine.

Educator, judge, public defender: Conflicting roles for remediators of practising physicians.

CONTEXT: Practising physicians who remediate their peers face unique challenges. Recent research suggests that leaders of regulatory and educational institutions (ie, those who might be seen as responsible for overseeing remediation programmes for practising physicians) view remediation as a duality: education and regulation. Research has yet to study the perspectives of remediators; therefore, to address that gap we asked: What is the nature of remediation as experienced by remediators? METHODS: We used a theory-informing inductive data analysis study design with positioning theory as a sensitising concept. We interviewed nine remediators from five Canadian provinces, asking them to narrate particularly memorable remediation experiences, then exploring the stories in more depth by asking probing questions around topics related to the research question. We used a hermeneutic analytic approach to explore the meanings that participants gave to their remediation work by iteratively reading their stories, examining the sense making that participants achieved through these narratives, and identifying the positions and responsibilities they described. RESULTS: In their remediation narratives, participants variably position themselves in three different ways: (a) educator; (b) judge, and (c) public defender. For each position, remediators in turn framed the remediatee in a particular way. Participants shifted between educator, judge and public defender in response to evolving experiences with the remediatee, but they expressed preference for the educator position. However, they sometimes encountered serious obstacles to enacting that educator position. Those obstacles were imposed both by regulators and by remediatees. CONCLUSIONS: This study suggests that the duality of remediation as both education and regulation may be contributing to the challenges faced by those working one to one with remediatees. Understanding the dual nature of remediation and equipping remediators with the tools to manage this duality might contribute to improving the experience for both remediators and remediatees, and ultimately to a greater number of successful remediation outcomes.

Towards a program of assessment for health professionals: from training into practice.

Despite multifaceted attempts to "protect the public," including the implementation of various assessment practices designed to identify individuals at all stages of training and practice who underperform, profound deficiencies in quality and safety continue to plague the healthcare system. The purpose of this reflections paper is to cast a critical lens on current assessment practices and to offer insights into ways in which they might be adapted to ensure alignment with modern conceptions of health professional education for the ultimate goal of improved healthcare. Three dominant themes will be addressed: (1) The need to redress unintended consequences of competency-based assessment; (2) The potential to design assessment systems that facilitate performance improvement; and (3) The importance of ensuring authentic linkage between assessment and practice. Several principles cut across each of these themes and represent the foundational goals we would put forward as signposts for decision making about the continued evolution of assessment practices in the health professions: (1) Increasing opportunities to promote learning rather than simply measuring performance; (2) Enabling integration across stages of training and practice; and (3) Reinforcing point-in-time assessments with continuous professional development in a way that enhances shared responsibility and accountability between practitioners, educational programs, and testing organizations. Many of the ideas generated represent suggestions for strategies to pilot test, for infrastructure to build, and for harmonization across groups to be enabled. These include novel strategies for OSCE station development, formative (diagnostic) assessment protocols tailored to shed light on the practices of individual clinicians, the use of continuous workplace-based assessment, and broadening the focus of high-stakes decision making beyond determining who passes and who fails. We conclude with reflections on systemic (i.e., cultural) barriers that may need to be overcome to move towards a more integrated, efficient, and effective system of assessment.

From behaviours to attributions: further concerns regarding the evaluation of professionalism.

OBJECTIVES: This study aimed to explore faculty attendings' scoring and opinions of students' written responses to professionally challenging situations. METHODS: In this mixed-methods study, 10 pairs of faculty attendings (attending physicians in internal medicine) marked responses to a professionalism written examination taken by 40 medical students and were then interviewed regarding their scoring decisions. Quantitatively, inter-rater scoring agreement was calculated for each pair and students' global scores were compared with a previously developed theoretical framework. Qualitatively, interviews were analysed using grounded theory. RESULTS: Inter-rater reliability in scoring was poor. There was also no correlation between faculty's scores and our previous theoretical framework; this lack of correlation persisted despite modifications to the framework. Qualitative analysis of faculty attendings' interviews yielded three major themes: faculty preferred responses in which students expressed insight, showed responsibility, and ultimately put the patient first. Faculty also expressed difficulty in deciding what was more important (the behaviour or the rationale behind it) and in assigning numerical scores to students' responses. Interestingly, they did not downgrade students for mentioning implications for themselves as long as these were balanced by other considerations. CONCLUSIONS: This study attempted to overcome some of the instability that results when we judge behaviours by making the rationales behind students' behaviours explicit. However, between-faculty agreement was still poor. This reinforces concerns that professionalism, as a subtle and complex construct, does not reduce easily to numerical scales. Instead of concentrating on creating the 'perfect' evaluation instrument, educators should perhaps begin to explore alternative approaches, including those that do not rely on numerical scales.

The Power of Subjectivity in the Assessment of Medical Trainees.

Objectivity in the assessment of students and trainees has been a hallmark of quality since the introduction of multiple-choice items in the 1960s. In medical education, this has extended to the structured examination of clinical skills and workplace-based assessment. Competency-based medical education, a pervasive movement that started roughly around the turn of the century, similarly calls for rigorous, objective assessment to ensure that all medical trainees meet standards to assure quality of health care. At the same time, measures of objectivity, such as reliability, have consistently shown disappointing results. This raises questions about the extent to which objectivity in such assessments can be ensured.In fact, the legitimacy of "objective" assessment of individual trainees, particularly in the clinical workplace, may be questioned. Workplaces are highly dynamic and ratings by observers are inherently subjective, as they are based on expert judgment, and experts do not always agree-for good, idiosyncratic, reasons. Thus, efforts to "objectify" these assessments may be problematically distorting the assessment process itself. In addition, "competence" must meet standards, but it is also context dependent.Educators are now arriving at the insight that subjective expert judgments by medical professionals are not only unavoidable but actually should be embraced as the core of assessment of medical trainees. This paper elaborates on the case for subjectivity in assessment.

Lessons From Rocket Science: Reframing the Concept of the Physician Health Advocate.

Health advocacy is a prominent component of health professionals' training internationally and is frequently discussed in the medical education literature. Despite this, it continues to be a problematic and challenging topic for medical educators, health professionals, and trainees alike. Borrowing from the field of systems engineering, the authors suggest a need to reconceptualize health advocacy using a systems mind-set rather than a physician-centric perspective. Conceptualizing health advocacy as a systemic, collective effort requires educators, practitioners, and trainees to challenge the assumption that the role of a competent physician health advocate can be fully defined without regard to the larger system or collective within which physicians function. Further, this implies a substantially more dynamic understanding of physicians' and other participants' parts in the collective activity.Of course, this new way of conceptualizing physicians' practices is not limited to health advocacy. The current education paradigm trains physicians for individual competency but expects them to practice collectively. Defining physician competen cies, or the competencies of any health care provider, in isolation from the particular system of which that individual is an integral part implicitly places that health care provider as the central focus of that system. Thus, academic medicine needs to move its educational and research efforts forward in a manner that recognizes that a systems engineering approach to health improvement will allow the various players to maximize their individual efforts to more effectively support the collective activity.