Critical ethnography: implications for medical education research and scholarship.

CONTEXT: Medical education (ME) must rethink the dominant culture's fundamental assumptions and unintended consequences on less advantaged groups and society at large. Doing so, however, requires a robust understanding of what we are teaching, regardless of our intentions, and what is being learned across the multiple settings that our learners find themselves in, from classrooms to clinical spaces and beyond. APPROACH: Gaining such understandings and fully exploring the extent to which we are rising to the challenges of today's society in authentic ways require robust methodologies. In this research approaches paper, we introduce unfamiliar readers to one such methodology-critical ethnography. By doing so, we hope to demonstrate its potential for helping ME both identify and gain novel insight into necessary solutions for many of today's educational challenges regarding healthcare disparities and inequities. CONCLUSION: The readers of this paper will gain novel insights into how critical ethnographers see the world and ask questions, thereby changing the way they (the reader) see the world. At its heart, critical ethnography is about thinking differently and that is something that should be accessible to all. Doing so may also enhance our ability to both question dominant ways of thinking and, ultimately, to enact positive change in training and practices to enhance inclusivity and fairness for all regardless of their gender, race and status.

"It's What We Can Do Right Now": Professional Identity Formation Among Internal Medicine Residents During the COVID-19 Pandemic.

PURPOSE: The COVID-19 pandemic represents a consequential moment of disruption for medical training that has far-reaching implications for professional identity formation (PIF). To date, this has not been studied. As medical education grapples with a postpandemic era, it is essential to gain insight into how the pandemic has influenced PIF to better support its positive influences and mitigate its more detrimental effects. This study examined how PIF occurred during the COVID-19 pandemic to better adapt future medical training. METHOD: Constructivist grounded theory guided the iterative data collection and analyses. The authors conducted semistructured group interviews with 24 Ontario internal medicine residents in postgraduate years (PGYs) 1 to 3 between November 2020 and July 2021. Participants were asked to reflect on their day-to-day clinical and learning experiences during the pandemic. RESULTS: Twenty-four internal medicine residents were interviewed (12 PGY-1 [50.0%], 9 PGY-2 [37.5%], and 3 PGY-3 [12.5%]). Participants described how navigating patient care and residency training through the pandemic consistently drew their attention to various system problems. How participants responded to these problems was shaped by an interplay among their personal values, their level of personal wellness or burnout, self-efficacy, institutional values, and the values of their supervisors and work community. As they were influenced by these factors, some were led toward acting on the problem(s) they identified, whereas others had a sense of resignation and deferred action. These interactions were evident in participants' experiences with communication, advocacy, and learning. CONCLUSIONS: Residents' professional identities are continuously shaped by how they perceive, reconcile, and address various challenges. As residents navigate tensions between personally held values and apparent system values, individuals in supervisory positions should be mindful of their influence as role models who empower values and practices that are recognized by participants to be important aspects of physician identity.

Talking About Notes: Using a Design-Based Research Approach to Develop a Discharge Summary Template on a Geriatric Inpatient Unit.

Background: Discharge summaries are important educational tools, guiding trainees in their collection and documentation of data. As geriatric competencies are integrated in medical curricula, documentation on in-patient geriatric rotations should represent the unique care and education provided, yet often follow generic templates. What content should be included in a geriatric discharge summary has not previously been explored and was the purpose of this study. Methods: A mixed-methods, designed-based research approach was used to assess note quality on a geriatric in-patient unit and iteratively co-develop a template with examples through three phases: 1) needs assessment, 2) consensus building, and 3) template development. Results: Sixty-eight discharge summaries were assessed by five geriatricians, with 14 gaps identified. Many of these reflected elements that were present but addressed generically without attention to the specificity required from a geriatric perspective. In response, the team developed a geriatric-specific template with explicit examples. Through the consensus process three barriers to quality notes and trainee education were identified: the chronic state of low-quality notes being accepted as the norm, time limitations due to the high volume of patients, and high volume of clinical documents. Conclusions: The identification of gaps in geriatric discharge summaries allowed for the co-development of an instructional template and examples that goes beyond simple headings and highlights the importance of applying and documenting geriatric competencies. Although we encourage others to take up and modify the tools for trainees in their local context, more importantly, we encourage them to take up the dialogue about note quality.

From helplessness to transformation: An analysis of clinician narratives about the social determinants of health and their implications for training and practice.

BACKGROUND: Medical curricula are attempting to prepare trainees to address the social determinants of health, however the life circumstances of patients are often beyond physician control. Little is known about how physicians cope with this dilemma; we sought to examine their perspectives when faced with this challenge to help better prepare trainees for practice. METHODS: We undertook a critical analysis of physician narratives from January 2018 to June 2020. In total, 268 physician-written narrative social determinant of health pieces from four high impact medical journals were screened and 47 met the inclusion criteria and were analysed. RESULTS: We identified four storylines that described the physician experience and strategies for coping with the social determinants of health. While Helplessness stories described authors' experiences of emotional distress when unable to support their patients, the other story types described ways they could make a difference. In Shortcoming and Transformation stories, the realisations about shortcomings led to transformation. In Doctor-patient relationship stories, authors described its importance in theirs and patients' lives, and in System advocacy stories, they described the need for greater advocacy to help change broken systems. CONCLUSIONS: Current approaches to teaching the social determinants of health often focus on the role of physicians in recognising and altering social circumstances. However, the realities of practice do not easily allow physicians to do so and, for some, may lead to distress and burnout. There are other ways to cope and make a difference by improving ourselves, investing in getting to know our patients, and advocating. These results can help better support trainees and physicians for the realities of practice.

Thresholds of becoming: an exploration of threshold concepts as a means to support professional identity formation in competency-based curricula.

Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training.

"Influential" Intraoperative Educators and Variability of Teaching Styles.

OBJECTIVES: Academic surgeons manage their role as intraoperative educators in a variety of ways. Such variability is neither idiosyncratic nor is there a single best approach. This study sought to explore the practices of surgeons deemed influential by their residents, allowing insight into a variety of potentially effective practices. PARTICIPANTS: Constructivist grounded theory guided data collection and analysis. Data sources included surveys from senior surgical residents (PGY3-6) and recent graduates from an academic hospital in Canada (36% response rate), intraoperative observations of teaching interactions, and semi-structured interviews with observed surgeons. Rigour was supported by data triangulation, constant comparison, and collection to theoretical sufficiency. DESIGN: We developed a framework grouping effective teaching into three overlapping approaches: exacting, empowering, and fostering. The approaches differ based on the level of independence granted and the degree of expectation placed on individual residents. Each demonstrates different strategies for balancing the multiple supervisory roles and patient care obligations faced by academic surgeons. We also identified strategies that could be used across approaches to enhance learning. CONCLUSIONS: For surgical educators seeking to improve upon the quality of the intraoperative supervision they provide, frameworks such as this may serve as models of effective supervision. Enhancing surgeons' knowledge of proven strategies, combined with reflecting on how they teach and how they balance responsibilities to patients and trainees, may allow them to broaden their educational practice.

Documentation as composing: how medical students and residents use writing to think and learn.

Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees.

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

Exploring implicit influences on interprofessional collaboration: a scoping review.

Interprofessional collaboration (IPC) is fraught with multiple tensions. This is partly due to implicit biases within teams, which can reflect larger social, physical, organizational, and historical contexts. Such biases may influence communication, trust, and how collaboration is enacted within larger contexts. Despite the impact it has on teams, the influence of bias on IPC is relatively under-explored. Therefore, the authors conducted a scoping review on the influence of implicit biases within interprofessional teams. Using scoping review methodology, the authors searched several online databases. From 2792 articles, two reviewers independently conducted title/abstract screening, selecting 159 articles for full-text eligibility. From these, reviewers extracted, coded, and iteratively analyzed key data using a framework derived from socio-material theories. Authors found that many studies demonstrated how biases regarding dominance and expertise were internalized by team members, influencing collaboration in predominantly negative ways. Articles also described how team members dynamically adapted to such biases. Overall, there was a paucity of research that described material influences, often focusing on a single material element instead of the dynamic ways that humans and materials are known to interact and influence each other. In conclusion, implicit biases are relatively under-explored within IPC. The lack of research on material influences and the relationship among racial, age-related, and gender biases are critical gaps in the literature. Future research should consider the longitudinal and reciprocal nature of both positive and negative influences of bias on collaboration in diverse settings.

Discharging the complex patient - changing our focus to patients' networks of care providers.

BACKGROUND: A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning. METHODS: This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical. RESULTS: We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network's scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial. CONCLUSIONS: Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Before the scalpel: Exploring surgical residents' preoperative preparatory strategies.

OBJECTIVE: This study sought to increase understanding of preoperative preparatory strategies utilised by senior surgical residents and identify how social and material forces come together to shape practice. SUMMARY/BACKGROUND DATA: Preoperative preparation can play a powerful role in operative learning. Residents rarely receive guidance, feedback, or explicit expectations on how to prepare for the OR. Understanding current practice and how to support preoperative preparation represents an important gap in our efforts to improve surgical training. METHODS: Constructivist grounded theory with sensitizing concepts from sociomateriality guided data collection and analysis. Fifteen senior surgical residents from a range of surgical disciplines were purposefully sampled and participated in an in-depth individual interview. Two return-of-finding focus groups followed with seven residents. Rigor was enhanced through constant comparison, theoretical sampling, pursuit of discrepant data, and investigator triangulation. RESULTS: Residents utilised a range of strategies addressing four areas of focus: develop technical skills, improve procedural knowledge, enhance patient-specificity, and know surgical preferences. However, residents also described receiving limited guidance on what it means to 'be prepared' and experience significant challenges in achieving preparedness. A mix of social and material things that enabled or constrained preparatory efforts influenced individual strategies. These included rotation structure, relationships, the OR list, and time. CONCLUSIONS: Our findings offer possible solutions by elaborating on preparatory variability and considerations for residents, faculty, and programs to improve practice. As a first step, we suggest programs begin to engage in explicit dialogue and reflection with their residents, faculty, and residency program committees.

Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study.

PURPOSE: A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time. METHODS: Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance. RESULTS: Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients. CONCLUSION: Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.

RéSUMé: OBJECTIF: Il existe une discordance, qui tend surtout vers un sur-traitement, entre les préférences exprimées par les patients pour les interventions de maintien de la vie et celles documentées lors de l'admission à l'hôpital. Cette étude d'amélioration de la qualité avait pour objectif d'évaluer cette discordance au sein de notre institution. Les objectifs secondaires de notre étude étaient d'explorer la possibilité que les équipes de médecine interne (MI) identifient les patients qui pourraient bénéficier de conversations approfondies et de voir si la discordance pouvait être corrigée en temps réel. MéTHODE: Deux infirmières ont intégré des équipes de MI dans un hôpital tertiaire pour discuter avec les patients hospitalisés de leurs préférences en matière de réanimation entre le 1er août 2016 et le 31 août 2018; les patients leur étaient soit spécifiquement référés (groupe I, n = 165), ou sélectionnés au hasard (groupe II, n = 164). Les préférences en matière de réanimation ont été documentées et communiquées aux équipes, entraînant une révision des ordonnances de réanimation, le cas échéant. La régression logistique multivariée a été utilisée afin de déterminer les facteurs de risque potentiels de discordance. RéSULTATS: Trois cent vingt-neuf patients ont été évalués, d'un âge moyen (écart type) de 80 ans (12) et avec un score de 6,8 (2,6) à l'Indice de comorbidité de Charlson. Une discordance a été identifiée chez 63/165 (38 %) et 27/164 (16 %) patients dans les groupes I et II, respectivement. Au total, 42/194 patients (21 %) ne souhaitaient pas de réanimation cardiorespiratoire (RCR) et 15/36 (41 %) préféraient ne pas être admis à l'unité de soins intensifs (USI), malgré une mention dans leurs préférences initiales. Parmi les patients chez lesquels une discordance a été notée, 93 % (84/90) ont préféré une désescalade des soins. La discordance a pu être corrigée pour 77 % (69/90) des patients. CONCLUSION: La documentation des patients hospitalisés pourrait indiquer des préférences pour des interventions de RCR et d'admission à l'USI contraires aux véritables préférences. Des infirmières formées à cet effet peuvent identifier les patients hospitalisés qui bénéficieraient d'une conversation approfondie sur leurs préférences en matière de réanimation. Une fois identifiée, une discordance peut être corrigée lors de l'admission initiale.

"Doing it Right" Overnight: a Multi-perspective Qualitative Study Exploring Senior Medical Resident Overnight Call.

BACKGROUND: Competency-based medical education (CBME) requires the development of workplace-based assessment tools that are grounded in authentic clinical work. Developing such tools, however, requires a deep understanding of the underlying facets of the competencies being assessed. Gaining this understanding remains challenging in contexts where performance is not readily visible to supervisors such as the senior medical resident (SMR) on-call role in internal medicine. OBJECTIVE: This study draws on the perspectives of healthcare professionals with whom the SMR interacts with overnight to generate insights into the different components of on-call SMR practice and the range of ways SMRs effectively and less effectively enact these. APPROACH: We used a constructivist grounded theory (CGT) approach to examine variation in how on-call SMRs carry out their role overnight. PARTICIPANTS: Six medical students, five junior residents, five internal medicine attending physicians, five emergency physicians, and three emergency nurses conducted observations of their on-call interactions with SMRs. Participants were then interviewed and asked to elaborate on their observations as well as provide comparative reflections on the practices of past SMRs they worked with. KEY RESULTS: Strong collaboration and organizational skills were identified as critical components to effectively being the on-call SMR. Perceived weaker SMRs, while potentially also having issues with clinical skills, stood out more when they could not effectively manage the realities of collaboration in a busy workplace. CONCLUSION: What consistently differentiated a perceived effective SMR from a less effective SMR was someone who was equipped to manage the realities of interprofessional collaboration in a busy workplace. Our study invites medical educators to consider what residents, particularly those in more complex roles, need to receive feedback on to support their development as physicians. It is our intention that the findings be used to inform the ways programs approach teaching, assessment, and the provision of feedback.

Innovating Pediatric Emergency Care and Learning Through Interprofessional Briefing and Workplace-Based Assessment: A Qualitative Study.

BACKGROUND: Managing pediatric emergencies can be both clinically and educationally challenging with little existing research on how to improve resident involvement. Moreover, nursing input is frequently ignored. We report here on an innovation using interprofessional briefing (iB) and workplace-based assessment (iWBA) to improve the delivery of care, the involvement of residents, and their assessment. METHODS: Over a period of 3 months, we implement an innovation using iB and iWBA for residents providing emergency pediatric care. A constructivist thematic analysis approach was used to collect and analyze data from 4 focus groups (N = 18) with nurses (4), supervisors (5), and 2 groups of residents (4 + 5). RESULTS: Residents, supervisors, and nurses all felt that iB had positive impacts on learning, teamwork, and patient care. Moreover, when used, iB seemed to play an important role in enhancing the impact of iWBA. Although iB and iWBA seemed to be accepted and participants described important impacts on emergency department culture, conducting of both iB and iWBA could be sometimes challenging as opposed to iB alone mainly because of time constraints. CONCLUSIONS: Interprofessional briefing and iWBA are promising approaches for not only resident involvement and learning during pediatric emergencies but also enhancing team function and patient care. Nursing involvement was pivotal in the success of the innovation enhancing both care and resident learning.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care.

PURPOSE: The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. METHOD: Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. RESULTS: The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). CONCLUSIONS: Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

"You Want Me to Assess What?": Faculty Perceptions of Assessing Residents From Outside Their Specialty.

PROBLEM: Competency-based medical education (CBME) demands that residents be directly observed performing clinical tasks; however, many faculty lack assessment expertise, and some programs lack resources and faculty numbers to fulfill CBME's mandate. To maximize limited faculty resources, the authors explored training and deploying faculty to assess residents in specialties outside their own. APPROACH: In spring 2017, 10 MD and 2 PhD assessors at a medium-sized medical school in Ontario, Canada, participated in a 4-hour training session, which focused on providing formative assessments of patient handover, a core competency of medical practice. Assessors were deployed to 2 clinical settings outside their own specialty-critical care and pediatrics-each completing 11 to 26 assessments of residents delivering patient handover. Assessors were subsequently interviewed regarding their experiences. OUTCOMES: While assessors felt able to judge handover performance outside their specialty, their sense of comfort varied with their own prior experiences in the given settings. Lack of familiarity with the process of handover in a specific setting directly influenced assessors' perceptions of their own credibility. Although assessors identified the potential benefits of cross-specialty assessment, they also cited challenges to sustaining this approach. NEXT STEPS: Findings indicate a possible "contextual threshold" for cross-specialty assessment: tasks with high context specificity might not be suitable for cross-specialty assessment. Introducing higher-fidelity simulation into the training protocol and ensuring faculty members are remunerated for their time are necessary to establish future opportunities for shared assessment resources across training programs.