Facilitating the transition to residency: A resident-as-coach pilot program.

BACKGROUND: The transition from medical school to residency is a critical developmental phase; coaching may help students prepare for this role transition. AIMS: We explored whether near-peer coaching could improve a specific workplace skill prior to residency. METHODS: A resident-as-coach program was piloted for the medicine sub-internship, an advanced acting internship rotation. Between March and June 2021, 26 students were assigned a resident coach (n = 16). Resident coaches completed one training session, and student-coach dyads met for one coaching session on 'pre-rounding'- gathering patient data before rounds. The program was evaluated through surveys and focus groups. RESULTS: 20/26 students and 14/16 residents completed the survey. 19/20 students identified a pre-rounding challenge and reported increased pre-rounding efficiency; all committed to one actionable step for improvement. All 16 residents felt their coaching skills improved. In focus groups, students valued the program's focus on honing a relevant skill in a safe, near-peer setting. Residents expressed their intent to incorporate coaching into their future work. CONCLUSIONS: A resident-as-coach model can be effective in preparing students for residency, while concurrently building residents' coaching skills.

"What's Going to Happen?": Internal Medicine Resident Experiences of Uncertainty in the Care of Older Adults.

PURPOSE: Internal medicine residents care for clinically complex older adults and may experience increased moral distress due to knowledge gaps, time constraints, and institutional barriers. We conducted a phenomenological study to explore residents' experiences and challenges through the lens of uncertainty. METHODS: Between January and March 2022, six focus groups were conducted comprising a total of 13 internal medicine residents in postgraduate years 2 and 3, who had completed a required 2-week geriatrics rotation. Applying the Beresford taxonomy of uncertainty as a conceptual model, data were analyzed using the framework method. RESULTS: All challenging experiences described by residents caring for older adults were linked to uncertainty. Sources of uncertainty were categorized and mapped to the Beresford taxonomy: (1) lack of geriatrics knowledge or clinical guidelines (technical); (2) difficulty applying knowledge to complex older adults (conceptual); and (3) lack of longitudinal relationship with the older patient (personal). Residents identified capacity evaluation and discharge planning as two major geriatric knowledge areas linked with uncertainty. While the majority of residents reacted to uncertainty with some degree of distress, several reported positive coping strategies. CONCLUSIONS: Internal medicine residents face uncertainty when caring for older adults, particularly related to technical and conceptual factors. Strategies for mitigating uncertainty in the care of older adults are needed given links with moral distress and trainee well-being.

Virtual training for small group facilitators.

BACKGROUND: In addition to providing patient care, interprofessional health care teams work collaboratively on a variety of projects. These projects often benefit from using facilitated small group project discussion sessions, such as the Harvard Macy Institute's (HMI) Step Back Process (SBP). Although having a trained facilitator is an important component of the SBP, only a limited number of health care professionals can attend HMI courses in person or virtually, limiting its impact. APPROACH: We developed three video-based education (VBE) modules to deliver facilitator training on the SBP, informed by principles of Mayer's cognitive theory of multimedia learning. For module development, we used a five-step approach. We evaluated effectiveness of the modules as a self-directed method to enhance SBP facilitator training. An initial survey collected demographic data and module feedback, a follow-up survey collected feedback on the modules' impact on facilitation and interviews focused on the participants' overall experience. EVALUATION: Survey results indicated that the modules were positively received and helped to improve participant confidence in facilitating. We identified four themes from the interviews: challenges of facilitating, value of group feedback, value of modules for experienced facilitators and the modules as part of a multi-modal approach to train new facilitators. IMPLICATIONS: This innovation provides insight on delivering facilitator training on the SBP using VBE. Health professions educators developing online facilitator training could adapt our development process and modify implementation guided by our results. Future work should evaluate the best methods to integrate VBE modules into a longitudinal virtual community and assess facilitation techniques.

Eureka moments: ICU physicians' views on teaching.

BACKGROUND: Teaching hospitals are fast-paced health care environments where clinical supervisors constantly balance teaching and patient care. Although hospital-based clinicians in acute care settings regularly teach trainees, views regarding their teaching roles and how this relates to professional satisfaction are less well studied. We explored perspectives of physicians who teach trainees in medical intensive care units (MICUs), to understand whether their engagement in teaching has any impact on professional (job) satisfaction. METHODS: This qualitative study used focus groups of MICU fellows (postgraduate clinical trainees) and attending physicians (consultants) to explore participants' perceptions of their teaching roles. Focus groups were audiotaped and transcribed; thematic analysis was conducted on de-identified transcripts. FINDINGS: Four focus groups were held; two with MICU attendings (n = 13) and two with MICU fellows (n = 12). We identified four key themes: two challenges of teaching (being a chameleon; calibrating learner abilities), one benefit of teaching (facilitating learners' eureka moments) and a call for professional development (peer coaching to enhance teaching skills). DISCUSSION: Although teaching in acute clinical environments requires balancing dynamic learner needs and complex patient care needs, participants found it highly rewarding. They called for peer coaching initiatives to enhance professional development as teachers and demonstrate departmental commitment to teaching. CONCLUSION: While teaching in acute clinical settings is challenging for many reasons, clinical teachers emphasise that it is very satisfying when learners see the 'light'. Overt institutional support and recognition for clinical teachers along with peer coaching and debriefing may tilt the balance towards the rewards side of the equation and foster professional satisfaction.

Transforming global health professions education for sustainability.

BACKGROUND: Health professions education (HPE) must keep pace with rapid shifts in learning and societal contexts, control of resources, knowledge and environmental concerns. Sustainability is increasingly seen as complex, balancing the three pillars of economy, society and the environment and addressing the current generation's needs without compromising future generations' needs. We aim to orient three-pillar sustainability in (HPE) from a decolonial global perspective. CONFERENCES AS TRUTH-REGIMES: Future-proofing imperatives compel HPE to respond to sustainability calls in contexts of globalisation and internationalisation. International conferences are sites of power in knowledge production and dissemination because themes and invited speakers determine who experts in the field are and what knowledge is important. Scholarly communities, dominating the discourse, determine the nature of reality or 'truth' (ontology), theoretical foundations of that reality and approaches to knowing (epistemology). Using one international conference as a case study, we found few scholarly presentations on sustainability, especially economic disparities. Discourse in HPE is still dominated by Global North 'experts'. IMPLICATIONS: Conferences are important discursive spaces for knowledge production and exchange. Increasing attention to social justice and planetary health must include a global perspective on three-pillar sustainability. Historical and contemporary perspectives about disparities on health should exceed Eurocentric epistemologies alone. These are areas ripe for innovative research in HPE. Promisingly, there is increasing attention to curricula around health equity, disparities and clinical rotations in rural and underserved communities among educational institutions around the world. CONCLUSIONS: Future-proofing HPE requires addressing three sustainability pillars simultaneously. Conferences as influential knowledge production spaces are mostly characterised by Global North to South flow of knowledge. Global North-dominated discourse fails to reflect on the impact of historical disparities including colonialism that thwart equivalence. Transforming HPE can occur through a sustainability perspective that advances three-pillar global approaches for inclusive global legitimacy in HPE narratives and standards.

Mentorship in health professions education - an AMEE guide for mentors and mentees: AMEE Guide No. 167.

This AMEE guide discusses theoretical principles and practical strategies for health professions educators to promote impactful mentoring relationships. Traditional definitions are challenged, distinctions are made between roles such as mentor, advisor, coach and sponsor. As educational environments change and options for professional development expand, we argue that the traditional dyadic format of mentoring alone will not help mentees to maximise their professional growth. Newer formats of mentoring are discussed in detail and their advantages and disadvantages compared. We use a variety of theoretical concepts to anchor the practice of mentorship: self-focussed and other-focussed motives; psychological safety; personal interpretive framework; Daloz model for balancing support and challenge; zone of proximal development; communities of practice; and development along multiple layers of competence. Recommended strategies for effective mentoring are based on extensive review of literature, as well as combined professional mentoring experiences of the authors. We use key principles from the theories described and phases of mentoring relationships as foundations for the suggested best practices of mentorship. Finally, we emphasise the role of mentees in their own professional development and provide tips for them on seeking mentors, expanding their mentoring network and taking the lead in setting the agenda during mentoring meetings and formulating action plans for their own advancement.

What do you think of when you hear the word 'feedback'? A reflective thematic analysis study of interviews.

PURPOSE: Although most teaching around feedback focuses on the delivery, one must consider that the word 'feedback' is not a neutral word. It inflicts a range of emotions that, when used, may influence the effectiveness of the feedback process. A more profound understanding of health professions educators' perceptions regarding the word 'feedback' can help explain discrepancies between the provision, reception and acceptance of feedback. METHODS: This is a qualitative inductive, reflective thematic analysis study. The authors interviewed 22 health professions educators participating in an online workshop to develop their feedback giving skills on their initial perspectives of the word 'feedback'. RESULTS: We found four major themes: (1) Can I tell you a little story about my feedback experience? (2) It is probably going to be negative. (3) There is always something to learn if you are willing to hear the message. (4) It is like getting a report card. From the data, we suggest one key antecedent and two practical approaches one could take when giving feedback. CONCLUSION: In this article, the authors highlight barriers during the feedback process due to the mere perception of the nature of feedback and the connotations associated with the term itself and suggest approaches that can refocus conversations towards a shared meaning and purpose of improvement, despite the preconceptions of the word 'feedback'.

Application of the R2C2 Model to In-the-Moment Feedback and Coaching.

PURPOSE: The R2C2 (relationship, reaction, content, coaching) model is an iterative, evidence-based, theory-informed approach to feedback and coaching that enables preceptors and learners to build relationships, explore reactions and reflections, confirm content, and coach for change and cocreate an action plan. This study explored application of the R2C2 model for in-the-moment feedback conversations between preceptors and learners and the factors that influence its use. METHOD: A qualitative study using framework analysis through the lens of experiential learning was undertaken with 15 trained preceptor-learner dyads. Data were collected during feedback sessions and follow-up interviews between March 2021 and July 2022. The research team familiarized themselves with the data, used a coding template to document examples of the model's application, reviewed the initial framework and revised the coding template, indexed and summarized the data, created a summary document, examined the transcripts for alignment with each model phase, and identified illustrative quotations and overarching themes. RESULTS: Fifteen dyads were recruited from 8 disciplines (11 preceptors were paired with a single resident [n = 9] or a single medical student [n = 2]; 2 preceptors each had 2 residents). All dyads were able to apply the R2C2 phases of building relationships, exploring reactions and reflections, and confirming content. Many struggled with the coaching components, specifically in creating an action plan and follow-up arrangements. Preceptor skill in applying the model, time available for feedback conversations, and the nature of the relationship impacted how the model was applied. CONCLUSIONS: The R2C2 model can be adapted to contexts where in-the-moment feedback conversations occur shortly after a clinical encounter. Experiential learning approaches applying the R2C2 model are critical. Skillful application of the model requires that learners and preceptors go beyond confirming an area of change and deliberately engage in coaching and cocreating an action plan.

Deeper look into feedback practice in an Indonesian context: exploration of factors in undergraduate clinical settings.

PURPOSE: The practice of feedback is influenced by the characteristics of students, teachers, and the clinical environment. Most studies on feedback have been conducted in Western settings with different sociocultural backgrounds to Indonesia. This study explores feedback in Indonesian clinical clerkship using a sociocultural lens and aims to provide an exemplar of adaptive practice relevant to non-Western settings. METHODS: This qualitative study was conducted using an interpretive phenomenology approach. Data were collected through focus groups with students and teachers and interviews with program coordinators. Data were transcribed verbatim and grouped according to data sources, coded, and analyzed thematically. RESULTS: Themes identified from the focus group discussions and interviews were categorized as student, teacher, and environmental factors. Student factors include dependence on feedback, tendencies to use a group approach, difficulties recognizing social rules, a perceived lack of resilience, and tendencies to doubt praise. Factors related to teachers include a high level of expertise, being extremely busy, having a strong commitment, and being unsure of students' acceptance of feedback. Clinical environment factors influence interactions between teachers and learners and include high power distance and collectivistic values. A safe environment is needed to ensure effective feedback interactions. CONCLUSION: High power distance, collectivism, and generational characteristics of students likely impact feedback practice in clinical settings. Designing a safe environment is essential for effective feedback practice.

Inclusion in global health professions education communities through many lenses.

In this paper, we reflect on what inclusion can mean to the global Health Professions Education (HPE) community, the impact of lack of inclusion, and offer suggestions on how to be inclusive. To illustrate the impact of inclusion, we offer perspectives from the lens of a medical student, junior doctor, educators, and educational leaders. The viewpoints offered in this communication can be useful to broaden and nurture inclusive pedagogy and scholarship. Furthermore, since the aim of HPE is high quality patient care and social advocacy, emphasising inclusion in HPE could enhance inclusion in patient care.

An age-friendly residency: Geriatrician and internist perspectives on geriatric education in an internal medicine residency.

BACKGROUND: General internists and subspecialists need skills to deliver age-friendly care to older adults, yet a minority of Internal Medicine (IM) residency programs provide robust geriatric-specific clinical instruction. We sought to explore internist and geriatrician perspectives regarding current strengths and weakness of geriatric education, and perceived supports, barriers, and strategies to enhance geriatric education in an IM residency program. METHODS: Using social learning theory as a conceptual framework, we conducted a needs assessment using focus groups and semi-structured interviews with IM residency leadership and geriatricians at an academic medical center. Interviews were recorded and transcribed; thematic analysis was performed on deidentified transcripts. RESULTS: We recruited faculty by e-mail in 2021; eight geriatricians and seven internists participated (60% female, 13% Hispanic/Latino, and 73% White). Six participated in two virtual focus groups and nine participated in virtual one-on-one interviews. All had at least monthly teaching contact with residents and six were associate program directors. We identified five key themes: (1) professional role models, (2) personal attitudes toward aging, (3) the powerful influence of patients, (4) clinical complexity of geriatrics, and (5) branding and prestige of the field. Participants offered multiple suggestions for improvement, especially faculty development for non-geriatrician faculty. CONCLUSIONS: Geriatric education for IM residents is impacted by multiple factors, but uniformly viewed as important. Moving forward, programs could capitalize on opportunities for closer collaboration between residency leadership, internists, and geriatricians to train the next generation of IM residency graduates to deliver age-friendly care.

Adaptive leadership during challenging times: Effective strategies for health professions educators: AMEE Guide No. 148.

Leadership and management are becoming increasingly recognised as vital for high-performing organisations and teams in health professions education. It is often difficult for those embarking on leadership activities (as well as more experienced leaders) to find their way through the volume of literature and generic information on the topic. This guide aims to provide a framework for developing educators' understanding of leadership, management, and followership in the context of health professions education. It explains many relevant approaches to leadership and suggests various strategies through which educators can develop their practice to become more effective.

From doing to leading: PGY-1 to PGY-2 transition.

BACKGROUND: Clinical trainees experience several professional transitions throughout their career, which can be exciting, anxiety-provoking or both. The first to second post-graduate year (PGY) transition for residents (junior doctors) in North America involves assuming new roles such as team leader, clinical supervisor, and teacher, often with minimal preparation. We explored resident experiences and emotions during this transition, and obtained their strategies for navigating this transition, through the lens of Bridges' transition model. This model has three stages: (1) ending, losing and letting go, (2) the neutral zone and (3) the new beginning. METHODS: We conducted one in-person focus group and subsequent one-on-one virtual semistructured interviews (due to COVID-19) of PGY-2 and PGY-3 residents who had previously undergone the transition. These sessions were recorded and transcribed, and thematic analysis was performed. FINDINGS: Four residents participated in the focus group, and 14 participated in one-on-one interviews. We identified five key themes: (1) not just a cog in the wheel, (2) contributing to growth of near-peers, (3) being flexible and adaptive, (4) emulating resident role models and (5) relationships with attendings. Residents suggested a transitions-focused retreat, simulation training to lead clinical emergencies, supervised opportunities for PGY-1s to act as PGY-2s coached by senior residents, and pairing PGY-1s with senior residents to help prepare for the transition. CONCLUSION: Professional transitions are both anxiety-provoking and exciting. Clinical trainees need preparation to successfully navigate multiple transitions. The Bridges' transition model could be useful in conceptualising transitions and planning curricula.

Nurse-doctor co-teaching: A path towards interprofessional collaboration.

BACKGROUND: Nurse-doctor collaborations are essential for team-based patient care. Although there are increasing calls for interprofessional education, teaching and learning together is rare. In 2019, we designed a Nurse-Doctor Co-Teaching pilot programme to provide an opportunity for nurses and doctors to co-teach junior doctors and nurses. We aimed to explore the experiences of the co-teachers and understand their perceptions of teaching together. The study was conducted through the lens of positioning theory. METHODS: We held an hour-long focus group discussion and follow-up one-on-one interviews with nurses and doctors who participated as co-teachers. Conversations were audio-video recorded, transcribed, and thematically analysed. The Partners Institutional Review Board approved this study. RESULTS: Three nurses and four doctors participated in the focus group conversation, and four nurses and two doctors participated in individual interviews. Participant narratives provided insight into shifts in hospital culture that would be necessary to promote effective interprofessional learning and collaboration: (1) break down professional silos, (2) invite the nursing perspective, (3) flatten professional hierarchies, and (4) recognise nurses as clinical teachers. CONCLUSION: Nurses and doctors felt they shared a collegial and equal partnership as co-teachers. But this relationship was not typical of their daily clinical roles. Institutional barriers presented challenges to collaboration on the hospital floor and nursing participation in teaching. Successful interprofessional education may require culture and policy shifts that formally recognise nurses as valuable clinical teachers.