The role of the supervisor in self-regulated learning in the clinical environment: BEME Guide No. 89.

INTRODUCTION: Self-regulated learning (SRL) in medical education is important for successful learning and safe patient care. However, supervisors may be unaware of behaviours that explicitly facilitate or inhibit their students' or residents' SRL, therefore this BEME review explores the role of the supervisor in SRL in clinical environments. METHODS: A qualitative systematic review using meta-aggregation was performed, seeking to draw on the knowledge of included studies and the participants those studies represent to create context-rich recommendations that are relevant and applicable to practice. Categories were developed from individual findings and then synthesised in the form of guidance. RESULTS: Twenty-two studies were included. Six categories were developed. A supervisor who facilitates SRL is: adaptive, engaged and supportive, builds trusting relationships, is knowledgeable, learner-centred, and crafts the architecture of the clinical learning environment. CONCLUSIONS: Within the categories, reciprocal trust and dialogue creates a positive cycle of supervisor-learner engagement which facilitates SRL, but due to the power imbalance inherent in the supervisor-learner relationship, the supervisor needs to make the first move. The curriculum has an important role to play in fostering supervisor-learner relationships. Supervisor beliefs about their role, and the architecture of the clinical learning environment can facilitate or inhibit SRL.

The Use of Art Observation Interventions to Improve Medical Students' Diagnostic Skills: A Scoping Review.

Introduction: Clinical observation skills are fundamental to the practice of medicine. Yet, the skill of looking carefully is rarely taught within the medical curriculum. This may be a contributory factor in diagnostic errors in healthcare. A growing number of medical schools, especially in the United States, have turned to the humanities to offer visual arts-based interventions to foster medical students' visual literacy. This research aims to map the literature on the relationship between art observation training and diagnostic skills of medical students, highlighting effective teaching methodologies. Methods: Based on the Arksey and O'Malley framework, a comprehensive scoping review was conducted. Publications were identified by searching nine databases and hand searching the published and grey literature. Two reviewers independently screened each publication using the pre-designed eligibility criteria. Results: Fifteen publications were included. Significant heterogeneity exists between the study designs and the methods employed to evaluate skill improvement. Nearly all studies (14/15) reported an increase in the number of observations made post-intervention, but none evaluated long-term retention rates. There was an overwhelmingly positive response to the programme, but only one study explored the clinical relevance of the observations made. Discussion: The review establishes improved observational acumen following the intervention, however, uncovers very limited evidence towards improved diagnostic abilities. There is a need for greater rigour and consistency within the experimental designs, through using control groups, randomisation, and a standardised evaluation rubric. Further research on the optimal intervention duration and the application of skills gained to clinical practice, should be performed.

The F3 phenomenon: Early-career training breaks in medical training. A scoping review.

BACKGROUND: Since 2017, more than 50% of UK doctors have undertaken a 'Foundation 3 (F3) Year' training break after completing their foundation programme (the first two years following graduation), rather than immediately enter specialty training. The reasons for, and consequences of, the growing F3 trend are largely unknown. This scoping review presents the current evidence and identifies future research in this field. METHODS: Following Arksey and O'Malley's guidelines, 12 databases and three UK-based national postgraduate organisation websites were searched for articles published in English (final searches January 2020). Multiple search terms were used to capture articles relating to the 'F3' time-period, including 'post-foundation' or 'pre-specialty' training. Title, abstract and full-paper screening selected articles reporting any aspect of F3, including within a wider context (eg postgraduate training breaks), and then underwent mixed-methods analysis. RESULTS: Of 4766 articles identified, 45 were included. All articles were published after 2009; 14/45 (31.1%) were published in 2019. 27 articles reported research, and the remainder were opinion/commentaries. Specific personal (including demographic), professional and organisational factors, particularly the UK postgraduate training structure, are associated with undertaking an F3. The majority of F3 training breaks last 1 year and involve working (clinically or non-clinically) and/or travel. The decision to undertake an F3 is made either prior to or during foundation training. Evidence regarding the impact of F3 on health care service provision was limited but evenly balanced. CONCLUSIONS: In summarising the existing F3 evidence, this review has highlighted important issues including health care workforce equality and diversity, training pathway inflexibility and the effect of negative early-career experiences on subsequent career decisions. More research is needed to understand the financial impact of training breaks on health care service provision, how training programmes must adapt to retain more trainees and the long-term effects of training breaks, such as F3, on subsequent career progression.

Trainee and supervisor experience of the Academic Foundation Programme.

BACKGROUND: The Academic Foundation Programme (AFP) is often the initial step along the Integrated Academic Training pathway in the UK. It is relatively new and research as to its effectiveness is limited. Our objective was to evaluate the AFP in terms of its impact on academic career aspirations and to explore trainees' expectations and experience of the programme and investigate the enablers and barriers to success. METHOD: Seven supervisors of Academic Foundation trainees were interviewed over a 5-month period in 2014. AFP trainees' views were sought by way of an online questionnaire that covered six areas: demographics, expectations, academic time, experience, research and achievements. RESULTS: Thirty-four trainees completed online questionnaires. The majority of trainees (94%) did not proceed directly along the Integrated Academic Training pathway to complete Academic Clinical Fellowships, but those who applied to do so were often successful (nine applicants, six successful). Free-text comments revealed an expectation of a more course-like structure to the programme, this is in contrast to the authentic experience of clinical academia, along with its associated challenges, that some of the supervisors reported. The importance of planning and preparation for success was a recurring theme from the supervisor interviews. CONCLUSIONS: The programme is achieving some success in encouraging academic careers. There are several areas that can be improved. Improving the availability of information and guidance for supervisors and facilitating Academic Foundation Doctors to network are both feasible changes that could lead to improvement.

Systematic review of interventions to encourage careers in academic medicine.

AIMS: Academic medicine is a career route that historically struggles to recruit and retain suitable doctors. The aim of this paper is to review the evidence for interventions to encourage careers in academic medicine by way of a descriptive systematic review. METHODS: Key databases were searched in February 2017. Studies that evaluated interventions to encourage careers in academic medicine and that used a pre-post analysis or included a comparison group were included. Interventions reporting only learner satisfaction were excluded. The review was specific to medical students and graduates. RESULTS: Twenty-four studies were identified for inclusion within the review. The included studies identified interventions across five domains: postgraduate funding, postgraduate training, mentoring, undergraduate interventions, and institutional change. The papers varied in terms of strength of conclusion and method of analysis with broad, structured, well-funded programs having the most palpable results. CONCLUSIONS: The five domains identified offer a framework that can be used by institutions who wish to develop similar programs. It also offers a body of research on which an evidence base can be built.

Twelve tips on how to compile a medical educator's portfolio.

Medical education is an expanding area of specialist interest for medical professionals. Whilst most doctors will be familiar with the compilation of clinical portfolios for scrutiny of their clinical practice and provision of public accountability, teaching portfolios used specifically to gather and demonstrate medical education activity remain uncommon in many non-academic settings. For aspiring and early career medical educators in particular, their value should not be underestimated. Such a medical educator's portfolio (MEP) is a unique compendium of evidence that is invaluable for appraisal, revalidation, and promotion. It can stimulate and provide direction for professional development, and is a rich source for personal reflection and learning. We recommend that all new and aspiring medical educators prepare an MEP, and suggest twelve tips on how to skillfully compile one.

Value of supervised learning events in predicting doctors in difficulty.

CONTEXT: In the UK, supervised learning events (SLE) replaced traditional workplace-based assessments for foundation-year trainees in 2012. A key element of SLEs was to incorporate trainee reflection and assessor feedback in order to drive learning and identify training issues early. Few studies, however, have investigated the value of SLEs in predicting doctors in difficulty. This study aimed to identify principles that would inform understanding about how and why SLEs work or not in identifying doctors in difficulty (DiD). METHODS: A retrospective case-control study of North West Foundation School trainees' electronic portfolios was conducted. Cases comprised all known DiD. Controls were randomly selected from the same cohort. Free-text supervisor comments from each SLE were assessed for the four domains defined in the General Medical Council's Good Medical Practice Guidelines and each scored blindly for level of concern using a three-point ordinal scale. Cumulative scores for each SLE were then analysed quantitatively for their predictive value of actual DiD. A qualitative thematic analysis was also conducted. RESULTS: The prevalence of DiD in this sample was 6.5%. Receiver operator characteristic curve analysis showed that Team Assessment of Behaviour (TAB) was the only SLE strongly predictive of actual DiD status. The Educational Supervisor Report (ESR) was also strongly predictive of DiD status. Fisher's test showed significant associations of TAB and ESR for both predicted and actual DiD status and also the health and performance subtypes. None of the other SLEs showed significant associations. Qualitative data analysis revealed inadequate completion and lack of constructive, particularly negative, feedback. This indicated that SLEs were not used to their full potential. CONCLUSIONS: TAB and the ESR are strongly predictive of DiD. However, SLEs are not being used to their full potential, and the quality of completion of reports on SLEs and feedback needs to be improved in order to better identify and manage DiD.

Physicians' Practice of Dispensing Medicines: A Qualitative Study.

OBJECTIVES: The physical act of giving medication to patients to administer away from a health care setting, dispensing, is normally performed by pharmacists. Dispensing of medication by physicians is a neglected patient safety issue, and having observed considerable variation in practice, the lead author sought to explore this issue further. A literature review yielded zero articles pertaining to this, so an exploratory study was commenced. The qualitative arm, relating to junior physicians' experience of, and training in, dispensing, is reported here. METHODS: Focus groups were conducted to explore the beliefs, ideas, and experiences of physicians-in-training pertaining to dispensing of medication. These were recorded and transcribed. The transcriptions were thematically analyzed using the grounded theory. RESULTS: The emergency department was the most common site of dispensing. No formal training in dispensing had been received. Informal training was variable in content and utility. The physicians felt that dispensing was part of their role. CONCLUSIONS: Despite being expected to dispense, and the patient safety issues involved in giving drugs to patients to use at home, physicians do not feel that they have been trained to undertake this task. These findings from 1 hospital raise questions about the wider quality and safety of this practice.

How can a postgraduate professional education and development course benefit general practitioners?: a qualitative study.

PURPOSE: The rationale for 'professional education and development' (PED) courses is to support general practitioners, enabling them to access a range of theoretical and practical skills within a supportive schema. It aims to identify whether and how a regional PED course has had a beneficial impact upon participants. METHODS: The study comprised a qualitative investigation of participants' assessed coursework portfolios. The content of each portfolio gives individual accounts of the impact of the course on personal and practice development. Permission to access extant portfolios was obtained from 16 recent alumni of the course. The anonymous written material was analysed by the research team for recurring discourses and themes using a thematic framework analysis. RESULTS: Seven major thematic categories were extrapolated from the data: leadership, resilience, quality improvement, change management, development of new services, educational expertise, and patient safety. In each category, we found evidence that the course enabled development of practitioners by enhancing knowledge and skills which had a positive impact upon their self-perceived effectiveness and motivation. CONCLUSION: Extended specialty training is on the horizon but such courses may still serve a valuable purpose for current trainees and the existing general practitioners workforce which will be responsible for leading the shift towards community-based service delivery.

A solid grounding: prescribing skills training.

BACKGROUND: Prescribing is an error-prone process for all doctors, from those who are newly qualified through to those at consultant level. Newly qualified doctors write the majority of in-patient prescriptions and therefore represent an opportunity for safety improvement. Attention to prescribing as a patient-safety issue and potential educational interventions to help improve the situation have been published, but offer little to inform educators why and how any interventions may succeed. In order to identify areas of good practice, and to provide evidence of areas requiring further investigation and innovation, we aimed to ascertain the full range of prescribing practices for final-year medical students and newly qualified doctors across a large geopolitical region of the UK. METHODS: A questionnaire methodology was used. One questionnaire was sent to those responsible for final-year education, and a further, different questionnaire was sent to those responsible for the training of newly qualified doctors, asking about prescribing education in their locality. Questionnaires were sent to 15 hospitals in total. Prescribing is an error-prone process for all doctors RESULTS: Twelve hospitals contributed to final-year medical student data: a response rate of 80 per cent. A variety of methods, including student assistantship, pharmacist-led skills sessions and practical assessment, were offered to varying degrees. Free-text responses identified opportunities for different prescribing education and support. All 15 hospitals provided data on doctors' education, with interventions including e-learning, assessment and support from ward-based pharmacists. DISCUSSION: Current education focuses on the technical and knowledge-based paradigm of prescribing. Human factors and the impact of electronic prescribing should play a part in future developments in prescribing education.

The impact of an integrated medical leadership programme.

PURPOSE: The purpose of this paper is to determine the impact of an integrated Medical Leadership Programme (MLP) on a cohort of participating specialty doctors and the NHS services with which they were engaged. DESIGN/METHODOLOGY/APPROACH: This was a qualitative study designed to obtain rich textual data on a novel training intervention. Semi-structured interviews were conducted with participating MLP trainees at fixed points throughout the programme in order to capture their experiences. Resulting data were triangulated with data from extant documentation, including trainees' progress reports and summaries of achievements. Recurring discourses and themes were identified using a framework thematic analysis. FINDINGS: Evidence of the positive impact upon trainees and NHS services was identified, along with challenges. Evidence of impact across all the domains within the national Medical Leadership Competency Framework was also identified, including demonstrating personal qualities, working with others, managing services, improving services and setting direction. RESEARCH LIMITATIONS/IMPLICATIONS: Data were drawn from interviews with a small population of trainees undertaking a pilot MLP in a single deanery, so there are inevitable limitations for generalisability in the quantitative sense. Whilst the pilot trainees were a self-selected group, it was a group of mixed origin and ability. PRACTICAL IMPLICATIONS: The study has provided valuable lessons for the design of future leadership programmes aimed at doctors in training. ORIGINALITY/VALUE: Identifying the effectiveness of an innovative model of delivery with regard to the Medical Leadership Curriculum may assist with medical staff engagement and support health service improvements to benefit patient care.

Why do medical trainees take time out of their specialty training programmes?

Postgraduate medical trainees may take time out of programme for personal or professional reasons which can delay completion of training. This survey of out of programme trainees in England explores a phenomenon that impacts significantly upon medical careers and workforce planning.

Clinical teaching: widening the definition.

BACKGROUND: In all medical specialities, trainees are increasingly encouraged to develop teaching skills alongside their clinical professional development. However, there have been few empirical UK-based studies that have examined trainees' attitudes and understanding of their own engagement with educational activities. This study therefore aimed to explore this in the context of general practitioner (GP) training using a qualitative approach. METHODS: Twenty GP registrars from the North Western Deanery were recruited to four focus groups. The data obtained using a semi-structured topic guide were analysed for thematic content, and the rigour of this methodology was increased by peer checking of the coding. Participation was voluntary and ethical approval was obtained. RESULTS: The majority of registrars interviewed initially presumed that teaching role development was only in relation to educating those junior to them, and thus followed a vertical hierarchical structure; however, during focus group discussions, the registrars started to recognise a range of other teaching modalities that they had not previously noted. These included peer-to-peer teaching sessions, examination preparation groups and, indeed, the everyday education of patients during consultations. DISCUSSION: Although this study has been conducted in the context of GP training, it is plausible to suggest that skewed perceptions from trainees as to what constitutes teaching may indeed exist in other speciality training schemes. There is therefore a need to shift current thinking around teaching engagement away from the traditional senior-junior relationship, and instead widen the definition of what it means to be involved in teaching activities.

The perceived benefits of a two-year period of extended specialty training in general practice: the trainees' perspective.

Evidence suggests that, in the UK, the current three-year specialty training period in general practice is inadequate for equipping newly qualified GPs with mastery in all the necessary clinical and generic skills that would allow them to respond with optimum effect to the complexities and uncertainties of the generalist workplace. The North Western Deanery initiated an innovative pilot programme of extended (by 24 months) specialty training in general practice (GPST4-5). Nine ST3 trainees who had just 'graduated' from GPST, holding nMRCGP, were recruited, thereby formally deferring their application for a Certificate of Completion of Training (CCT). The programme was evaluated using established qualitative research techniques. Semi-structured interviews were conducted at fixed points and data were analysed for recurring discourses and themes using a framework thematic analysis. We obtained evidence of the benefits of extended specialty training in encouraging the development of clinical mastery alongside additional specialist skills, generalist and leadership competencies. We also identified the enabling factors for beneficial extended training, including workplace-based training under educational mentorship, combined with a blended learning programme and sustained expert- and peer-support.

The motivation to teach as a registrar in general practice.

The General Medical Council (GMC) states that teaching should be an integral part of the doctor's role and the Royal College of General Practitioners (RCGP) have incorporated teaching outcomes into the GP training curriculum. However, there are suggestions that the teaching role of a GP trainee declines as they move from hospital posts to the registrar community year. Using doctors in training as near-peer tutors offers multiple advantages. Trainees themselves benefit as teaching others is a strong driver of the tutor's own learning. In addition there are also practical incentives to mobilising this under-utilised pool of primary care clinical teachers given the continuing shift of focusing medical education in the community. This study forms part of a larger body of work exploring the attitudes and perceived learning needs of GP registrars with regards to developing a teaching role. A primary area of investigation was trainees' motivation to teach. This paper describes our attempts to establish: a) how strongly motivated are GP registrars to take on teaching roles? b) in consequence how strongly motivated are they to learn more about teaching? c) what are the factors which affect motivation to teach? Three themes emerged from the data. First, teaching was felt to be of low priority in comparison to competing clinical learning needs. Secondly, the clinical dominance to both formative and summative assessment during training further compounded this situation. Thirdly, registrars identified a number of practical barriers and incentives that influenced their teaching engagement. This included potential negative views from trainers as to their trainee's ability and requirement to be involved with teaching activities.
By understanding and addressing these issues, it is hoped that GP trainees' engagement with teaching activities can be better engendered with subsequent benefits for both the trainee and those they teach.

Educator appraisal--occurrence and experience of hospital consultants in north-west England.

BACKGROUND: It is recommended all hospital consultants with educational responsibilities undergo appraisal of their educational role by their employer: a key component of revalidation. To support this process locally, the North Western Deanery developed guidance on educational appraisal. We wished to establish the frequency and perceived value of educator appraisal. METHODS: A web-based questionnaire of 605 hospital consultants with educational responsibilities in north-western England was conducted to collect data. RESULTS: Only 17.7% had been appraised for their educational responsibilities in the previous 36 months despite 92.7% undergoing appraisal of clinical work. Educational leads were statistically more likely to have had educational appraisal than educational supervisors (ES), similarly ES were more likely to have had appraisal than clinical supervisors (CS). Clinical specialty does not appear to be a major determining factor. The majority found the supporting documentation helpful in guiding data collection and subsequent recording of evidence. All respondents felt appraisals were conducted in a supportive manner with 76.6% stating appraisal had reassured them they were fulfilling their educational roles and helped 78.5% to identify an education personal development plan. CONCLUSIONS: The incidence of educator appraisal remains low but the experience is considered valuable and contributes effectively to educators' professional development.