Integrated and implicit: how residents learn CanMEDS roles by participating in practice.

CONTEXT: Learning outcomes for residency training are defined in competency frameworks such as the CanMEDS framework, which ultimately aim to better prepare residents for their future tasks. Although residents' training relies heavily on learning through participation in the workplace under the supervision of a specialist, it remains unclear how the CanMEDS framework informs practice-based learning and daily interactions between residents and supervisors. OBJECTIVES: This study aimed to explore how the CanMEDS framework informs residents' practice-based training and interactions with supervisors. METHODS: Constructivist grounded theory guided iterative data collection and analyses. Data were collected by direct observations of residents and supervisors, combined with formal and field interviews. We progressively arrived at an explanatory theory by coding and interpreting the data, building provisional theories and through continuous conversations. Data analysis drew on sensitising insights from communities of practice theory, which provided this study with a social learning perspective. RESULTS: CanMEDS roles occurred in an integrated fashion and usually remained implicit during interactions. The language of CanMEDS was not adopted in clinical practice, which seemed to impede explicit learning interactions. The CanMEDS framework seemed only one of many factors of influence in practice-based training: patient records and other documents were highly influential in daily activities and did not always correspond with CanMEDS roles. Additionally, the position of residents seemed too peripheral to allow them to learn certain aspects of the Health Advocate and Leader roles. CONCLUSIONS: The CanMEDS framework did not really guide supervisors' and residents' practice or interactions. It was not explicitly used as a common language in which to talk about resident performance and roles. Therefore, the extent to which CanMEDS actually helps improve residents' learning trajectories and conversations between residents and supervisors about residents' progress remains questionable. This study highlights the fact that the reification of competency frameworks into the complexity of practice-based learning is not a straightforward exercise.

What supervisors say in their feedback: construction of CanMEDS roles in workplace settings.

The CanMEDS framework has been widely adopted in residency education and feedback processes are guided by it. It is, however, only one of many influences on what is actually discussed in feedback. The sociohistorical culture of medicine and individual supervisors' contexts, experiences and beliefs are also influential. Our aim was to find how CanMEDS roles are constructed in feedback in a postgraduate curriculum-in-action. We applied a set of discourse analytic tools to written feedback from 591 feedback forms from 7 hospitals, including 3150 feedback comments in which 126 supervisors provided feedback to 120 residents after observing their performance in authentic settings. The role of Collaborator was constructed in two different ways: a cooperative discourse of equality with other workers and patients; and a discourse, which gave residents positions of power-delegating, asserting and 'taking a firm stance'. Efficiency-being fast and to the point emerged as an important attribute of physicians. Patients were seldom part of the discourses and, when they were, they were constructed as objects of communication and collaboration rather than partners. Although some of the discourses are in line with what might be expected, others were in striking contrast to the spirit of CanMEDS. This study's findings suggest that it takes more than a competency framework, evaluation instruments, and supervisor training to change the culture of workplaces. The impact on residents of training in such demanding, efficiency-focused clinical environments is an important topic for future research.

A feedback system in residency to evaluate CanMEDS roles and provide high-quality feedback: Exploring its application.

INTRODUCTION: Residents benefit from regular, high quality feedback on all CanMEDS roles during their training. However, feedback mostly concerns Medical Expert, leaving the other roles behind. A feedback system was developed to guide supervisors in providing feedback on CanMEDS roles. We analyzed whether feedback was provided on the intended roles and explored differences in quality of written feedback. METHODS: In the feedback system, CanMEDS roles were assigned to five authentic situations: Patient Encounter, Morning Report, On-call, CAT, and Oral Presentation. Quality of feedback was operationalized as specificity and inclusion of strengths and improvement points. Differences in specificity between roles were tested with Mann-Whitney U tests with a Bonferroni correction (α = 0.003). RESULTS: Supervisors (n = 126) provided residents (n = 120) with feedback (591 times). Feedback was provided on the intended roles, most frequently on Scholar (78%) and Communicator (71%); least on Manager (47%), and Collaborator (56%). Strengths (78%) were mentioned more frequently than improvement points (52%), which were lacking in 40% of the feedback on Manager, Professional, and Collaborator. Feedback on Scholar was more frequently (p = 0.000) and on Reflective Professional was less frequently (p = 0.003) specific. DISCUSSION AND CONCLUSION: Assigning roles to authentic situations guides supervisors in providing feedback on different CanMEDS roles. We recommend additional supervisor training on how to observe and evaluate the roles.

Effectiveness of a supervisor training on quality of feedback to internal medicine residents: a controlled longitudinal multicentre study.

OBJECTIVES: High-quality feedback on different dimensions of competence is important for resident learning. Supervisors may need additional training and information to fulfil this demanding task. This study aimed to evaluate whether a short and simple training improves the quality of feedback residents receive from their clinical supervisors in daily practice. DESIGN: Longitudinal quasi-experimental controlled study with a pretest/post-test design. We collected multiple premeasurements and postmeasurements for each supervisor over 2 years. A repeated measurements ANOVA was performed on the data. SETTING: Internal medicine departments of seven Dutch teaching hospitals. PARTICIPANTS: Internal medicine supervisors (n=181) and residents (n=192). INTERVENTION: Half of the supervisors attended a short 2.5-hour training session during which they could practise giving feedback in a simulated setting using video fragments. Highly experienced internal medicine educators guided the group discussions about the feedback. The other half of the supervisors formed the control group and received no feedback training. OUTCOME MEASURES: Residents rated the quality of supervisors' oral feedback with a previously validated questionnaire. Furthermore, the completeness of the supervisors' written feedback on evaluation forms was analysed. RESULTS: The data showed a significant increase in the quality of feedback after the training F (1, 87)=6.76, p=0.04. This effect remained significant up to 6 months after the training session. CONCLUSIONS: A short training session in which supervisors practise giving feedback in a simulated setting increases the quality of their feedback. This is a promising outcome since it is a feasible approach to faculty development.