Residents, Responsibility, and Error: How Residents Learn to Navigate the Intersection.

PURPOSE: As a competency of Canadian postgraduate education, residents are expected to be able to promptly disclose medical errors and assume responsibility for and take steps to remedy these errors. How residents, vulnerable through their inexperience and hierarchical team position, navigate the highly emotional event of medical error is underexplored. This study examined how residents experience medical error and learn to become responsible for patients who have faced a medical error. METHOD: Nineteen residents from a breadth of specialties and years of training at a large Canadian university residency program were recruited to participate in semistructured interviews between July 2021 and May 2022. The interviews probed their experience of caring for patients who had experienced a medical error. Data collection and analysis were conducted iteratively using a constructivist grounded theory method with themes identified through constant comparative analysis. RESULTS: Participants described their process of conceptualizing error that evolved throughout residency. Overall, the participants described a framework for how they experienced error and learned to care for both their patients and themselves following a medical error. They outlined their personal development of understanding error, how role modeling influenced their thinking about error, their recognition of the challenge of navigating a workplace environment full of opportunities for error, and how they sought emotional support in the aftermath. CONCLUSIONS: Teaching residents to avoid making errors is important, but it cannot replace the critical task of supporting them both clinically and emotionally when errors inevitably occur. A better understanding of how residents learn to manage and become responsible for medical error exposes the need for formal training as well as timely, explicit discussion and emotional support both during and after the event. As in clinical management, graded independence in error management is important and should not be avoided because of faculty discomfort.

Repeated use of rich pictures to explore changes in subjective experiences over time of patients with advanced cancer.

BACKGROUND: The combination of verbal and visual tools may help unravel the experiences of advanced cancer patients. However, most previous studies have focused on a specific symptom, at only one moment in time. We recently found that a specific visual tool, originating from systems thinking, that is, rich pictures (RPs), could provide a more comprehensive view of the experiences of patients with advanced cancer. AIMS: To examine whether the repeated use of RPs can make changes in subjective experiences of patients living with advanced cancer visible over time. METHODS AND RESULTS: We performed a prospective study with a generic qualitative approach that was mostly informed by the process of grounded theory. We invited patients to make an RP twice, at the start of the study, and again after 2 months. Both RP drawing sessions were directly followed by a semi-structured interview. Patients with all types of solid tumors, above the age of 18, and with a diagnosis of advanced, incurable cancer, were eligible. Eighteen patients participated and 15 patients were able to draw an RP twice. In eight RP-sets, considerable differences between the first and second RP were noticeable. Two patterns were distinguished: (1) a change (decline or improvement) in physical health (five patients), and/or (2) a change in the way patients related to cancer (three patients). CONCLUSION: RPs are a valuable qualitative research method that can be used to explore the experiences of patients with advanced cancer, not only at a single point in time but also over time.

On collective self-healing and traces: How can swarm intelligence help us think differently about team adaptation?

BACKGROUND: Health care teams are increasingly forced to navigate complex challenges to achieve their collective aim of delivering high-quality, safe patient care. The teamwork literature has struggled to develop strategies that promote effective adaptive behaviours among health care teams. In part, this challenge stems from the fact that truly collective adaptive behaviour requires members of the teams to abandon the human urge to act self-sufficiently. Nature contains striking examples of collective behaviour as seen in social insects, fish and bird colonies. This collective behaviour is known as Swarm Intelligence (SI). SI remains poorly described in the health care team literature and its potential benefits hidden. OBJECTIVE: In this cross-cutting edge paper, I explore the principles of SI as they pertain to systemic or collective adaptation in human teams. In particular, I consider the principles of trace-based communication and collective self-healing and what they might offer to team adaptation researchers in medical education. RESULTS: From a SI perspective, a solution to a problem emerges as a result of the collective action of the members of the swarm, not the individual action. This collective action is achieved via four principles: direct and indirect communication, awareness, self-determination and collective self-healing. Among those principles, trace-based communication and collective self-healing have been purposefully used by other industries to foster team adaptation. Trace-based communication relies on leaving 'traces' in the environment to drive the behaviour of others. Collective self-healing is the ability of the swarm to cope with failure and adapt to changes by permitting swarm members to be interchangeable. CONCLUSIONS: While allowing teams to rely on indirect communication and to be interchangeable might create discomfort to our ways of thinking, teams outside health care are demonstrating their value to advance human teamwork. SI offers a helpful analogy and a constructive language for thinking about team adaptation.

Exploring patients' and physicians' perspectives about competent health advocacy.

INTRODUCTION: Many residency programmes struggle to demonstrate how they prepare trainees to become competent health advocates. To meaningfully teach and assess it, we first need to understand what 'competent' health advocacy (HA) is and what competently enacting it requires. Attempts at clarifying HA have largely centred around the perspectives of consultant physicians and trainees. Without patients' perspectives, we risk training learners to advocate in ways that may be misaligned with patients' needs and goals. Therefore, the purpose of our research was to generate a multi-perspective understanding about the meaning of competence for the HA role. METHODS: We used constructivist grounded theory to explore patients' and physicians' perspectives about competent health advocacy. Data were collected using photo elicitation; patients (n = 10) and physicians (n = 14) took photographs depicting health advocacy that were used to inform semi-structured interviews. Themes were identified using constant comparative analysis. RESULTS: Physician participants associated HA with disruption or political activism, suggesting that competence hinged on medical and systems expertise, a conducive learning environment, and personal and professional characteristics including experience, status and political savvy. Patient participants, however, equated physician advocacy with patient centredness, perceiving that competent HAs are empathetic and attentive listeners. In contrast to patients, few physicians identified as advocates, raising questions about their ability to train or to thoughtfully assess learners' abilities. CONCLUSION: Few participants perceived HA as a fundamental physician role-at least not as it is currently defined in curricular frameworks. Misperceptions that HA is primarily disruptive may be the root cause of the HA problem; solving it may rely on focusing training on bolstering skills like empathy and listening not typically associated with the HA role. Since there may be no competency where the patient voice is more critical, we need to explore opportunities for patients to facilitate learning for the HA role.

Journey into uncertainty: Medical students' experiences and perceptions of failure.

CONTEXT: Having succeeded in being selected for medical school, medical students are not always familiar with failure and yet they are expected to graduate prepared to effectively function in the failure-burdened arena of clinical medicine. Lacking in the developing literature on learners and failure is an exploration of how this transformation is accomplished. The purpose of this study was to examine how medical students perceive and experience failure during their medical school training. METHOD: We used a qualitative description methodology to probe the failure experiences of medical students attending a Canadian medical school. Participants were provided with the broad definition of failure used in this research: 'deviation from expected and desired results.'In total, 12 students were sampled, three from each of the 4 years of study, and participated in individual, semi-structured interviews that were analysed using thematic analysis to identify and describe core themes. RESULTS: At the start of medical school, students admitted limited experience with failure; their early descriptions were self-centred and binary. Personal stories recounted by preceptors encouraged students and helped them understand that physicians are human and that failure is inevitable. Students felt relatively protected from failures that could impact patients. Both witnessing and participating in a failure event were distressing and sometimes at odds with their expectations. Students expressed a desire to talk about the experience. CONCLUSIONS: Medical students described examples of experiencing failure during medical school that transported them from the more certain black and white beginnings of their classroom into the uncertain shades of grey of clinical medicine. What the participants heard, saw and experienced suggests opportunities for classroom teachers to better prepare pre-clinical students for the inevitability of failure in clinical medicine and opportunities for clinical teachers to engage in open, inclusive conversations surrounding failures that occur on their watch.

Trainee-environment interactions that stimulate motivation: A rich pictures study.

CONTEXT: Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees' aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees' motivation and how they are intertwined. METHODS: We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results. RESULTS: Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees' motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus. CONCLUSIONS: Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.

Understanding helping behaviors in an interprofessional surgical team: How do members engage?

OBJECTIVE: In surgical environments, work must be flexible, allowing practitioners to seek help when required. How surgeons navigate the complexity of interprofessional teams and collaborative care whilst attending to their own knowledge/skill gaps can be difficult. This study aims to understand helping behaviours in interprofessional surgical teams. DESIGN: Thirteen semi-structured interviews with participants were completed. Data collection and inductive analysis were conducted iteratively using thematic analysis. RESULTS: We found several intersecting features that influenced helping engagement. Work context, including nested and cross-sectional identities, physical and hierarchical environments, diversity, support for risk-taking and innovation and perceptions of a "speak up" culture shaped the way helping scenarios were approached. Intrinsic attributes influenced decisions to dis/engage. When united, these features shaped how helping behaviours became enacted. CONCLUSION: If we desire to create surgical teams that deliver quality care, we must consider not only individual attributes but the context in which teams are situated.

Living with advanced cancer: Rich Pictures as a means for health care providers to explore the experiences of advanced cancer patients.

BACKGROUND: To provide holistic care to patients with advanced cancer, health care professionals need to gain insight in patients' experiences across the different domains of health. However, describing such complex experiences verbally may be difficult for patients. The use of a visual tool, such as Rich Pictures (RPs) could be helpful. We explore the use of RPs to gain insight in the experiences of patients with advanced cancer. METHODS: Eighteen patients with advanced cancer were asked to draw a RP expressing how they experienced living with cancer, followed by a semi-structured interview. Qualitative content analysis, including the examination of all elements in the drawings and their interrelationships, was used to analyze the RPs, which was further informed by the interviews. RESULTS: The RPs clearly showed what was most important to an individual patient and made relations between elements visible at a glance. Themes identified included: medical aspects, the experience of loss, feelings related to loss, support from others and meaningful activities, and integration of cancer in one's life. The added value of RPs lies in the ability to represent these themes in one single snapshot. CONCLUSIONS: RPs allow for a complementary view on the experiences of advanced cancer patients, as they show and relate different aspects of patients' lives. A RP can provide health care professionals a visual summary of the experiences of a patient. For patients, telling their story to health care professionals might be facilitated when using RPs.

Pimping in Residency: The Emotional Roller-Coaster of a Pedagogical Method - A Qualitative Study Using Interviews and Rich Picture Drawings.

Phenomenon: Pimping has become a well-known and distinct form of questioning in medical education, and as a pedagogical method it has both proponents and detractors. Pimping occurs when a teacher (pimper) asks difficult questions of the learner (pimpee), usually in rapid succession. There is a paucity of literature formally studying this technique and its effects on teachers and learners. Our study examines the use of and attitudes toward pimping in a pathology residency program to better understand its perceived value and effectiveness. Approach: Using a qualitative approach, we conducted semistructured interviews with 8 pathology trainees and 9 pathologists. As part of the interview process, we asked participants to draw a rich picture of a pimping encounter. Consistent with this qualitative method, we analyzed data iteratively using constant comparison. Findings: Negative emotions including anxiety and self-doubt dominated among the learners during pimping encounters. For some, these resulted in motivation to study, and for others this was a futile, nonmotivating experience. Most trainees felt that they were being judged during pimping; however, they perceived that the intentions of pimping were not malicious and in their best interests. This was supported by pathologists, who stated that their motivation for pimping was to identify knowledge gaps, thus benefiting the trainee. Insights: Pimping created a dichotomy of emotions within the majority of learners in this study. Negative emotions occurred during pimping encounters; however, following the encounter, pimping was perceived in a more positive light. Recognizing when and how pimping can create negative emotions that may interfere with learning may enable educators to create more consistently meaningful interactions.

Rich pictures: a companion method for qualitative research in medical education.

CONTEXT: Within the social sciences, researchers increasingly build on visual methods to explore complex phenomena and understand how people experience and give meaning to this complexity. Amongst the variety of visual methods available, rich pictures are beginning to gain traction in health professions education (HPE) research. APPROACH: A rich picture is a pictorial representation of a particular situation, including what happened, who was involved, how people felt, how people acted, how people behaved, and what external pressures they acted upon. Rich pictures expand our perspective; they may highlight connections, illuminate the big picture and reveal unexpected emotions. Although new methods bring excitement to the field, it is our responsibility to also be cautious and insightful about their limitations. Rich pictures are a method in evolution in HPE research, with many unknowns about what is possible and what is optimal. PURPOSE: In the current paper, we aim to map out the background, describe the process and share some reflective insights of using rich pictures as a data collection method.

Some assembly required: tracing the interpretative work of Clinical Competency Committees.

OBJECTIVES: This qualitative study describes the social processes of evidence interpretation employed by Clinical Competency Committees (CCCs), explicating how they interpret, grapple with and weigh assessment data. METHODS: Over 8 months, two researchers observed 10 CCC meetings across four postgraduate programmes at a Canadian medical school, spanning over 25 hours and 100 individual decisions. After each CCC meeting, a semi-structured interview was conducted with one member. Following constructivist grounded theory methodology, data collection and inductive analysis were conducted iteratively. RESULTS: Members of the CCCs held an assumption that they would be presented with high-quality assessment data that would enable them to make systematic and transparent decisions. This assumption was frequently challenged by the discovery of what we have termed 'problematic evidence' (evidence that CCC members struggled to meaningful interpret) within the catalogue of learner data. When CCCs were confronted with 'problematic evidence', they engaged in lengthy, effortful discussions aided by contextual data in order to make meaning of the evidence in question. This process of effortful discussion enabled CCCs to arrive at progression decisions that were informed by, rather than ignored, problematic evidence. CONCLUSIONS: Small groups involved in the review of trainee assessment data should be prepared to encounter evidence that is uncertain, absent, incomplete, or otherwise difficult to interpret, and should openly discuss strategies for addressing these challenges. The answer to the problem of effortful processes of data interpretation and problematic evidence is not as simple as generating more data with strong psychometric properties. Rather, it involves grappling with the discrepancies between our interpretive frameworks and the inescapably subjective nature of assessment data and judgement.

How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study.

PURPOSE: Error is inevitable in medicine, given its inherent uncertainty and complexity. Errors can teach powerful lessons; however, because of physicians' self-imposed silence and the intricacies of responsibility and blame, learning from medical error has been underexplored. The purpose of this study was to understand how physicians perceived learning from medical errors by exploring the tension between responsibility and blame and factors that affected physicians' learning. METHOD: Nineteen physicians participated in semistructured interviews, conducted in 2016-2017 at Western University in Canada, that probed their experiences in learning from medical errors. Data collection and analysis were conducted iteratively, with themes identified through constant comparative analysis. RESULTS: Participants felt personal responsibility and blame for their errors. Residency produced particularly salient memories of errors. Participants identified interconnecting cultural factors (normalizing error, peer support and mentorship, formal rounds) and individual factors (emotional response, confidence and experience), which either helped or hindered their perceived learning. CONCLUSIONS: Learning from medical error requires navigation through blame and responsibility. The keen responsibility felt by physicians must be acknowledged when enacting a system-based approach to medical error. Adopting a learning culture perspective suggests opportunities to enable and disable features of the learning environment to optimize learning from error as residents learn to become the most responsible physician for all outcomes. A better understanding of the factors that shape learning from error can help make the transition from error to learning more explicit, thereby increasing the opportunity to learn and teach from errors that permeate the practice of medicine.

Navigating complexity in team-based clinical settings.

CONTEXT: Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. METHODS: Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. RESULTS: Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. CONCLUSIONS: Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.

Qualitative research essentials for medical education.

This paper offers a selective overview of the increasingly popular paradigm of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations and outline principles of rigour. Examples are provided from our own and other authors' published qualitative medical education research. Our aim is to provide both an introduction to some qualitative essentials for readers who are new to this research paradigm and a resource for more experienced readers, such as those who are currently engaged in a qualitative research project and would like a better sense of where their work sits within the broader paradigm.

Being a surgeon or doing surgery? A qualitative study of learning in the operating room.

CONTEXT: A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery. METHODS: Using a multi-site ethnographic and practice-based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students' participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices. RESULTS: By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training. CONCLUSIONS: The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high-quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery.

Mastery Learning - does the method of learning make a difference in skills acquisition for robotic surgery?

BACKGROUND: Few studies compare the effectiveness of blocked vs random practice conditions in minimally invasive surgery training, and none have evaluated these in robotic surgery training. METHODS: The dV-Trainer® and the da Vinci® Surgical System (dVSS) were used to compare practice conditions. Forty-two participants were randomized into blocked and random practice groups. Each participant performed five tasks: Ring Walk, Thread the Rings, Needle Targeting, Suture Sponge and Tubes Level 2. Transfer to the dVSS was also assessed. RESULTS: No significant differences were observed between the two groups, except for a few instances. For example, during Ring Walk, the random group performed significantly faster than the blocked group (100.78 ± 5.26 s vs 121.59 ± 5.26 s, p < 0.01). CONCLUSIONS: The study results do not follow the current evidence presented in the education literature. This is the first time that blocked versus random practice was tested for robotic surgery training.

Thinking like an expert: surgical decision making as a cyclical process of being aware.

BACKGROUND: Education researchers are studying the practices of high-stake professionals as they learn how to better train for flexibility under uncertainty. This study explores the "Reconciliation Cycle" as the core element of an intraoperative decision-making model of how experienced surgeons assess and respond to challenges. METHODS: We analyzed 32 semistructured interviews using constructivist grounded theory to develop a model of intraoperative decision making. Using constant comparison analysis, we built on this model with 9 follow-up interviews about the most challenging cases described in our dataset. RESULTS: The Reconciliation Cycle constituted an iterative process of "gaining" and "transforming information." The cyclical nature of surgeons' decision making suggested that transforming information requires a higher degree of awareness, not yet accounted by current conceptualizations of situation awareness. CONCLUSIONS: This study advances the notion of situation awareness in surgery. This characterization will support further investigations on how expert and nonexpert surgeons implement strategies to cope with unexpected events.

The call, the save, and the threat: understanding expert help-seeking behavior during nonroutine operative scenarios.

OBJECTIVE: Asking for help in the operating room occurs within a surgical culture that has traditionally valued independence, decisiveness, and confidence. A tension exists between these deeply ingrained character traits and the new culture of team-based practice that emphasizes maximizing patient safety. The objective of this study is to explore surgeon-to-surgeon help-seeking behaviors during complex and unanticipated operative scenarios. STUDY DESIGN: Semistructured interviews were conducted with a purposeful sample of 14 consultant surgeons from multiple specialties. We used constructivist grounded theory to explore help-seeking experiences. Analysis occurred alongside and informed data collection. Themes were identified iteratively using constant comparisons. SETTING: The setting included 3 separate hospital sites in a Canadian academic health sciences center. PARTICIPANTS: A total of 14 consultant surgeons from 3 separate departments and 7 divisions were included. RESULTS: We developed the "Call-Save-Threat" framework to conceptualize the help-seeking phenomenon. Respondents highlighted both explicit and tacit reasons for calling for help; the former included technical assistance and help with decision making, and the latter included the need for moral support, "saving face," and "political cover." "The Save" included the provision of enhanced technical expertise, a broader intraoperative perspective, emotional support, and a learning experience. "The Threat" included potential downsides to calling, which may result in near-term or delayed negative consequences. These included giving up autonomy as primary surgeon, threats to a surgeon's image as a competent practitioner, and a failure to progress with respect to independent judgment and surgical abilities. CONCLUSIONS: Our "Call-Save-Threat" framework suggests that surgeons recurrently negotiate when and how to seek help in the interests of patient safety, while attending to the traditional cultural values of autonomy and decisive action. This has important implications for surgical postgraduate education and also throughout a surgeon's career trajectory.

What's behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations.

PURPOSE: Physicians regularly encounter challenging and/or complex situations in their practices; in training settings, they must help learners understand such challenges. Context becomes a fundamental construct when seeking to understand what makes a situation challenging and how physicians respond to it; however, the question of how physicians perceive context remains largely unexplored. If the goal is to teach trainees to deal with challenging situations, the medical education community requires an understanding of what "challenging" means for those in charge of training. METHOD: The authors relied on visual methods for this research. In 2013, they collected 40 snapshots (i.e., data sets) from a purposeful sample of five faculty surgeons through a combination of interviews, observations, and drawing sessions. The analytical process involved three phases: analysis of each drawing, a compare-and-contrast analysis of multiple drawings, and a team analysis conducted in collaboration with three participating surgeons. RESULTS: Findings demonstrate that experts perceive the challenge of surgical situations to extend beyond their procedural dimensions to include unspoken, nonprocedural dimensions-specifically, team dynamics, trust, emotions, and external pressures. CONCLUSIONS: Findings show that analysis of surgeons' drawings is an effective means of gaining insight into surgeons' perceptions. The findings refine the common belief that procedural complexity is what makes a surgery challenging for expert surgeons. Focusing exclusively on the procedure during training may put trainees at risk of missing the "big picture." Understanding the multidimensionality of medical challenges and having a language to discuss these both verbally and visually will facilitate teaching around challenging situations.