Complexities of Continuing Professional Development in Context: Physician Engagement in Clinical Coaching.

INTRODUCTION: Effective continuing professional development (CPD) is critical for safe and effective health care. Recent shifts have called for a move away from didactic CPD, which often fails to affect practice, toward workplace learning such as clinical coaching. Unfortunately, coaching programs are complex, and adoption does not guarantee effectiveness. To resolve this problem, thus ensuring resources are well spent, there is a critical need to understand what physicians try to achieve and how they engage. Therefore, we examined the types of change physicians pursue through clinical coaching and the impact of context on their desired changes. METHODS: In the context of two clinical coaching programs for rural physicians, we applied a generic qualitative approach. Coachees (N = 15) participated in semistructured interviews. Analysis involved iterative cycles of initial, focused, and theoretical coding. RESULTS: Coachees articulated desired practice changes along a spectrum, ranging from honing their current practice to making larger changes that involved new skills outside their current practice; changes also ranged from those focused on individual physicians to those focused on the practice system. Desired changes were affected by factors in the learning/practice environment, including those related to the individual coachee, coach, and learning/practice context. DISCUSSION: These results suggest that the current focus on acquiring new knowledge through CPD may miss important learning that involves subtle shifts in practice as well as learning that focusses on systems change. Moreover, an appreciation of the contextual nature of CPD can ensure that contextual affordances are leveraged and barriers are acknowledged.

Pedagogical validity: The key to understanding different forms of 'good' teaching.

The interrelationship of pedagogical skills, educational ends, and underlying values and assumptions constitute a teacher's 'pedagogical validity' - who they are as a teacher and why they teach the way they do. If reflection, judgment, and improvement are to be helpful, they must have regard for a more complete understanding of what frames a teacher's pedagogical validity. This article briefly describes four kinds of pedagogical validity that teachers draw upon when explaining or justifying their notion of 'good' teaching. Teachers generally have some part of each, but most of us draw upon one or two more than all four as we define ourselves as teachers and make sense of our teaching.

Working in the dead of night: exploring the transition to after-hours duty.

CONTEXT: Transitions, although often difficult, represent integral components of medical training. New postgraduate trainees (first-year residents) find themselves in an especially challenging transition as they are expected to fulfil both learning and service expectations concurrently. Workplace learning theory has been suggested as a lens through which to understand this unique educational, yet service-oriented, role. This tension may be further amplified overnight when residents are on-call with little to no support. OBJECTIVES: The aims of this study were to explore the transition from medical student to resident with respect to the on-call experience, and to provide theory-based suggestions to enhance learning during this unique transition. METHODS: We conducted an interpretivist qualitative study by interviewing eight medical students and 10 first-year residents from six different specialty training programmes across four academic sites. Each semi-structured interview was transcribed verbatim and anonymised. Resident interview transcripts were initially coded for major themes, after which medical student interview transcripts were coded for consistencies and discrepancies. RESULTS: Four interrelated themes were identified in students' and residents' descriptions of on-call experiences: (i) shift in responsibility; (ii) supervisory support; (iii) contextual conditions, and (iv) clarity of expectations. Generally, students were not able to anticipate the challenges they would face as residents on-call, and residents perceived the transition as sudden with little emphasis placed on learning. CONCLUSIONS: First-year residents face multiple challenges during on-call, which may prevent optimal learning in this setting. These challenges are amplified by the large gap between the respective roles of medical students and residents. We identified promoters of and barriers to effective learning in this environment and, by using workplace learning theory, provide recommendations for how we might be able to enhance medical students' preparation for and first-year residents' learning during experiences of being on-call.

Honoring Thyself in the Transition to Online Teaching.

Increasingly, health professions education (HPE) faculty are choosing or being required to transition their face-to-face teaching to online teaching. For many faculty, the online learning environment may represent a new context with unfamiliar technology, changing expectations, and unknown challenges. In this context, faculty members may find themselves teaching in ways that are dissonant with the existing assumptions, beliefs, and views that are central to their pedagogical or teaching identity. This "identity dissonance" may lead to dissatisfaction and frustration for faculty members and potentially suboptimal learning experiences for students. In this Perspective, the authors propose that faculty consider using Pratt's five teaching perspectives as a conceptual framework to recognize and mitigate potential identity dissonance as they transition to teaching online. Derived and refined through several years of research, these teaching perspectives are based on interrelated sets of intentions and beliefs that give direction and justification to faculty members' actions. They have been used in higher education to improve faculty satisfaction, self-reflection capabilities, and faculty development. The authors, therefore, believe that these teaching perspectives hold the potential to help HPE faculty enhance their teaching and retain their primary teaching identify, even as they shift to online teaching. Doing so may ensure that the components of teaching they enjoy and draw self-efficacy from are still central to their teaching experience. Pratt's teaching perspectives also provide a conceptual framework for creating future faculty development initiatives and conducting research to better understand and improve the experience of transitioning to online teaching.

A framework for negotiating positionality in phenomenological research.

This Guide was written as an aid to those who are considering phenomenology as a methodology in their education research. Phenomenology allows us to understand and appreciate educational issues by exploring the unique experiences and perspectives of individuals involved in the process. There are certain core tenets to all phenomenological research, such as a focus on exploring experience and adopting a phenomenological stance. However, because phenomenology has emerged from the work of a number of related but distinct philosophers, phenomenologists do not adhere to a single approach. To help phenomenological researchers position themselves and their work with regard to the various approaches, we offer the "3 + 1" framework. This framework articulates three dimensions on which phenomenological researchers vary: (1) focusing primarily on the general or the particular; (2) managing "pre-understandings" using primarily reduction or reflexivity; and (3) engaging with participants' stories using primarily description or interpretation. We suggest that a researcher need not adhere to a single position with regard to these dimensions, but rather should intentionally and reflectively shift across the various positions depending on purpose and context. The fourth aspect of the framework, writing, overlays these three dimensions, and is central to the reflective enactment of the phenomenological process.

Adapting the forms of yesterday to the functions of today and the needs of tomorrow: a genealogical case study of clinical teaching units in Canada.

Emergent discourses of social responsibility and accountability have in part fuelled the expansion of distributed medical education (DME). In addition to its potential for redressing physician maldistribution, DME has conferred multiple unexpected educational benefits. In several countries, its recent rise has occurred around the boundaries of traditional medical education practices. Canada has been no exception, with DME proliferating against a backdrop of its longstanding central node, the clinical teaching unit (CTU). The CTU first appeared just over 50 years ago with its position in Canadian health care largely taken-for-granted. Given the increasing prominence of DME, however, it is timely to reconsider what the place of tertiary centre-based practices such as the CTU might be in shifting medical education systems. From a genealogical perspective, it becomes clear that the CTU did not just "happen". Rather, its creation was made possible by multiple interrelated cultural, social, and political changes in Canadian society that, while subtle, are powerfully influential. Making them visible offers a better opportunity to harmonize the benefits of longstanding entities such as the CTU with novel practices such as DME. In so doing, the medical education field may sidestep the pitfalls of investing significant resources that may only produce superficial changes while unwittingly obstructing deeper transformations and improvements. Although this work is refracted through a Canadian prism, reconceptualizing the overall design of medical education systems to take advantage of both tradition and innovation is a persistent challenge across the international spectrum, resistant to tests of time and constraints of context.

Part versus whole: a randomized trial of central venous catheterization education.

Central venous catheterization (CVC) is a complex but commonly performed procedure. How best to teach this complex skill has not been clearly delineated. We conducted a randomized trial of the effects of two types of teaching of CVC on skill acquisition and retention. We randomly assigned novice internal medicine residents to learning CVC in-part or in-whole. The part-group was taught the first part of the procedure, followed by practice, followed by being taught the second and final portion of the procedure, and followed by practice. The whole-group was taught the procedure in its entirety, followed by practice. Teaching and practice time for both groups was otherwise held constant. Performances were assessed at baseline, post-training, and at 1 month. The primary outcome was skill retention at 1-month, rated by using a global rating scale and a 22-item checklist, and defined as the score increase between 1-month and baseline. Skill acquisition is defined as the score increase post-training and baseline. Raters were blinded to the participants' identity, group assignment, and time point. Participants in the part-task group outperformed the whole-task group in skill acquisition (2.2 ± 0.8 vs 1.3 ± 1.0; g = 1.01; p = 0.04) and in skill retention (1.5 ± 0.7 vs 0.5 ± 0.8; g = 1.39; p = 0.006) using the global rating scale. Scores rated by the checklist were not significantly different (52.0 ± 25.3 vs 43.5 ± 23.4; g = 0.33; p = 0.47 for skill acquisition; and 48.5 ± 34.9 vs 41.1 ± 20.4; g = 0.35; p = 0.44 for skill retention). For teaching ultrasound-guided CVC to novice learners, teaching in part is preferable than teaching in whole.

Residents' views of the role of classroom-based learning in graduate medical education through the lens of academic half days.

PURPOSE: To examine the role of classroom-based learning in graduate medical education through the lens of academic half days (AHDs) by exploring residents' perceptions of AHDs' purpose and relevance and the effectiveness of teaching and learning in AHDs. METHOD: The authors invited a total of 186 residents in three programs (internal medicine, orthopedic surgery, and hematology) at the University of British Columbia Faculty of Medicine to participate in semistructured focus groups from October 2010 to February 2011. Verbatim transcripts of the interviews underwent inductive analysis. RESULTS: Twenty-seven residents across the three programs volunteered to participate. Two major findings emerged. Purpose and relevance of AHDs: Residents believed that AHDs are primarily for knowledge acquisition and should complement clinical learning. Classroom learning facilitated consolidation of clinical experiences with expert clinical reasoning. Social aspects of AHDs were highly valued as an important secondary purpose. Perceived effectiveness of teaching and learning: Case-based teaching engaged residents in critical thinking; active learning was valued. Knowledge retention was considered suboptimal. Perspectives on the concept of AHDs as "protected time" varied in the three programs. CONCLUSIONS: Findings suggest that (1) engagement in classroom learning occurs through participation in clinically oriented discussions that highlight expert reasoning processes; (2) formal classroom teaching, which focuses on knowledge acquisition, can enhance informal learning occurring during clinical activity; and (3) social aspects of AHDs, including their role in creating communities of practice in residency programs and in professional identity formation, are an important, underappreciated asset for residency programs.

Resident education in the systems-based practice competency.

More than 10 years after the establishment of the six core competencies by the Accreditation Council for Graduate Medical Education, systems-based practice remains an elusive subject to teach, measure, and document. A wide variety of methods have been reported that address teaching and assessing performance for the discrete parts of systems-based practice; however, no single approach has been described that encompasses the competency in its entirety. To better understand the current state of this competency, orthopaedic residents and educators from around the country were surveyed to determine which systems-based practice topics were being taught at their institutions, how these topics were being taught, and how resident performance was assessed. Seven focus group sessions were held with members involved in the care of musculoskeletal patients to determine what they believed were essential skills for residents to learn relative to the healthcare system. Using this information, a health systems rotation was created for first-year residents that incorporated several different teaching and assessment methods. This rotation has received positive feedback from residents, patients, and health professionals. Its effect on resident development will be tracked over the next 5 years.

Clinical reasoning in dentistry: a conceptual framework for dental education.

This study presents a conceptual framework for clinical reasoning by dental students. Using a think-aloud method with six vignettes, the researchers interviewed eighteen dental students from two stages of training about oral health-related problems influenced by biopsychosocial factors. Verbatim transcripts of the interviews were analyzed to identify the processes and strategies of clinical reasoning used by the students to produce treatment plans. The process included 1) rituals to collect information; 2) forward and backward reasoning to generate and test clinical hypotheses; 3) pattern recognition from integrated scripts of knowledge and experience; and 4) decision trees to assess options and outcomes. The process was supplemented by scientific, conditional, collaborative, narrative, ethical, pragmatic, and part-whole reasoning strategies. Senior students showed a keen awareness of the contextual determinants of care and emphasized patients' motivations for treatment. In contrast, junior students focused more on problems associated with individual teeth as they struggled to integrate the information within each vignette. In this article, the processes and strategies for reasoning used by both groups of dental students are abstracted and then illustrated by a model of clinical reasoning that accommodates the complicated contexts in which clinical problems usually arise.

Reshaping orthopaedic resident education in systems-based practice.

BACKGROUND: Despite advances in understanding the "systems-based practice" competency in resident education, this topic has remained difficult to teach, assess, and document. The goal of this study was to perform a needs assessment and an analysis of the current state of systems-based practice education in orthopaedic residency programs across the U.S. and within our own institution. METHODS: A sample of orthopaedic educators and residents from across the U.S. who were attending the 2010 American Orthopaedic Association (AOA) Effective Orthopaedic Educator Course, AOA Resident Leadership Forum, and AOA Council of Residency Directors meeting were surveyed to determine (1) which aspects of systems-based practice, if any, were being taught; (2) how systems-based practice is being taught; and (3) how residency programs are assessing systems-based practice. In addition, an in-depth case study of these issues was performed by means of seven semi-structured focus group sessions with diverse stakeholders who participated in the care of musculoskeletal patients at the authors' institution. A quantitative approach was used to analyze the survey data. The focus group data were analyzed with procedures associated with grounded theory, relying on a constant comparative method to develop salient themes arising from the discussion. RESULTS: "Clinical observation" (33%) and "didactic case-based learning" (23%) were reported by the survey respondents as the most commonly used teaching methods, but specific topics were taught inconsistently. Competency assessment was reported to occur infrequently, and 36% of respondents reported that systems-based practice areas were not being assessed by any methods. The focus group discussions emphasized the need for standardized experiential learning that was closely linked to the patient's perspective. Orthopaedic faculty members were uncomfortable with their knowledge of this competency and their ability to teach and assess it. CONCLUSIONS: Teaching the systems-based practice competency occurs inconsistently, and formal assessment occurs infrequently. In addition to formal teaching, learning systems-based practice will be best achieved experientially and from the patient's perspective.

Competency is not enough: integrating identity formation into the medical education discourse.

Despite the widespread implementation of competency-based medical education, there are growing concerns that generally focus on the translation of physician roles into "measurable competencies." By breaking medical training into small, discrete, measurable tasks, it is argued, the medical education community may have emphasized too heavily questions of assessment, thereby missing the underlying meaning and interconnectedness of how physician roles shape future physicians. To address these concerns, the authors argue that an expanded approach be taken that includes a focus on professional identity development. The authors provide a conceptual analysis of the issues and language related to a broader focus on understanding the relationship between the development of competency and the formation of identities during medical training. Including identity alongside competency allows a reframing of approaches to medical education away from an exclusive focus on "doing the work of a physician" toward a broader focus that also includes "being a physician." The authors consider the salient literature on identity that can inform this expanded perspective about medical education and training.

Teaching plastic surgery from different perspectives.

Just as everyone has a different learning style, teachers too approach the task from different perspectives. There are five basic teaching perspectives or styles: transmission, apprenticeship, developmental, nurturing, and social justice. The acronym BIAS is useful to describe the beliefs, intentions, assessments, and strategies associated with each perspective. The authors present a hypothetical 1-week rotation in plastic and reconstructive surgery in which a student encounters instructors who embody the five basic teaching perspectives. By presenting these perspectives, the authors introduce valuable teaching techniques that can benefit all those charged with the education of learners along the spectrum from premedical to continuing education venues. Educational objectives include the following: (1) explain and illustrate different approaches to effective teaching in plastic surgery; (2) introduce readers to the Teaching Perspectives Inventory as a means of determining their primary teaching style; and (3) argue for a "plurality of the good" in teaching.

"Teaching as a Competency": competencies for medical educators.

Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the "Teaching as a Competency" conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College's Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learner-centeredness, adaptability, and self-reflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learner- centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then cross-referenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework's strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

Do spouses know how much fatigue, pain, and physical limitation their partners with rheumatoid arthritis experience? Implications for social support.

OBJECTIVE: To determine whether perceptions of clinical manifestations (fatigue, pain, and physical limitation) of rheumatoid arthritis (RA) differ between spouses and their partners with RA, and to determine whether the differences are associated with the perception of beneficial and problematic spousal social support. METHODS: English-speaking adults with RA of ≥ 6 months' duration and their spouses (n = 222 couples) completed standardized questionnaires for fatigue, pain, physical limitation, beneficial spousal support, and problematic spousal support. Spouses completed questionnaires based on their perception of their partner with RA. Agreement scores for fatigue, pain, and physical limitation were calculated by subtracting spouse scores from the scores of the partner with RA. Agreement levels were defined a priori: agreement (within ± one-half of a minimum clinically important difference [MCID] unit), overestimator (< one-half an MCID), and underestimator (> one-half an MCID). Separate hierarchical linear regression models were used to measure the association between beneficial support and problematic support after adjusting for RA duration, physical health, sex, educational level, relationship duration, and satisfaction. RESULTS: Response rate for couples was 82%. Relative to participants with RA, spouses overestimated fatigue (26%), pain (29%), and physical limitation (39%), and underestimated fatigue (11%), pain (17%), and physical limitation (34%). After statistically controlling for demographic, disease, and psychosocial variables, participants with RA whose spouses underestimated fatigue received more problematic support (R(2) = 3.7%, P = 0.002), as did those whose spouses underestimated or overestimated physical limitation (R(2) = 3.4%, P = 0.017). CONCLUSION: Persons with RA perceived more problematic spousal support when their spouse underestimated fatigue, or underestimated or overestimated physical limitation levels.

The power of one: looking beyond the teacher in clinical instruction.

BACKGROUND: Research on clinical teaching in medicine tends to focus on preceptors and senior attending physicians as the primary source of learning for medical students. As a result, there is an artificial separation of 'teacher' from context in much of the research on clinical teaching in medicine. AIMS: The central aim of this study was to challenge the taken-for-granted assumption that student learning can be attributed primarily to a preceptor or attending physician on a rotation. METHODOLOGY: Twenty-two medical students and forty-one clinical faculty members generated explanations for a study that showed a positive effect on NMBE results for 3rd year clerkship students who had at least one highly effective clinical teacher during their clinical rotation in medicine. RESULTS: Student and faculty explanations resulted in fourteen factors and six propositions describing the nature of highly effective clinical teaching. Students believed contextual factors influenced their own learning, but did not comment on that possibility in the study (Griffith CH, Georgesen JC, Wilson JF. 2000. Six-year documentation of the association between excellent clinical teaching and improved student examination performance. Acad Med 75(10): October Supplement). Most clinical faculty did question the assumption that one teacher could have that effect. CONCLUSIONS: We recommend refocusing research on clinical instruction toward engagement within a community of professionals, rather than attributing 'power' to a single clinical teacher.

Developing the master educator: cross disciplinary teaching scholars program for human and veterinary medical faculty.

OBJECTIVE: At the University of California, Davis (UCD), the authors sought to develop an institutional network of reflective educational leaders. The authors wanted to enhance faculty understanding of medical education's complexity, and improve educators' effectiveness as regional/national leaders. METHODS: The UCD Teaching Scholars Program is a half-year course, comprised of 24 weekly half-day small group sessions, for faculty in the School of Medicine and Veterinary Medicine. The program's philosophical framework was centered on personal reflection to enhance change: 1) understanding educational theory to build metacognitive bridges, 2) diversity of perspectives to broaden horizons, 3) colleagues as peer teachers to improve interactive experiences, and 4) reciprocal process of testing theory and examining practice to reinforce learning. The authors describe the program development (environmental analysis, marketing, teaching techniques), specific challenges, and failed experiments. The authors provide examples of interactive exercises used to enhance curricular content. The authors enrolled 7-10 faculty per year, from a diverse pool of current and near-future educational leaders. RESULTS: Four years of Teaching Scholars participants were surveyed about program experiences and short/longer term outcomes. Twenty-six (76%) respondents reported that they were very satisfied with the course (4.6/5), individual curricular blocks (4.2-4.6), and other faculty (4.7). They described participation barriers/facilitators. Participants reported positive impact on their effectiveness as educators (100%), course directors (84%), leaders (72%), and educational researchers (52%). They described specific acquired attitudes, knowledge, and skills. They described changes in their approach to education/career changed based on program participation. Combining faculty from different educational backgrounds significantly broadened perspectives, leading to greater/new collaboration. DISCUSSION: Developing a cadre of master educators requires careful program planning, implementation, and program/participant evaluation. Based on participant feedback, our program was a success at stimulating change. This open assessment of programmatic strengths and weaknesses may provide a template for other medical institutions that seek to enhance their institutional educational mission.

How dentists account for social responsibility: economic imperatives and professional obligations.

This study explores how dentists explain the concept of social responsibility and its relationship to issues affecting access to oral health care by vulnerable segments of the population. Analysis of open-ended interviews with thirty-four dentists, including dental educators, and administrators and officials of dental public health programs in Canada and the United States revealed that four main themes-economics, professionalism, individual choice, and politics-influenced the respondents' sense of social responsibility in dentistry. There was a belief that social responsibility in dentistry is dominated by economic imperatives that impact negatively on the policies and practices directing access to care. Yet, despite the highly critical stance on dentistry as a business, there was practical recognition of the economic realities of dental practice. Nevertheless, those who focused on social responsibility as a professional obligation highlighted the privileges of self-governance along with the accompanying duty to serve the welfare of everyone and not just those who are socioeconomically advantaged.