Storylines of Trauma in Health Professions Education: A Critical Metanarrative Review.

PHENOMENON: Learners in medical education are often exposed to content and situations that might be experienced as traumatic, which in turn has both professional and personal implications. The purpose of this study was to synthesize the literature on how trauma has been conceptualized and approached within medical education, and the implications thereof. APPROACH: A metanarrative approach was adopted following the RAMESES guidelines. Searches of 7 databases conducted in January 2022 with no date limitations yielded 7,280 articles, of which 50 were identified for inclusion through purposive and theoretical sampling. An additional 5 articles were added from manual searches of reference lists. Iterative readings, interpretive and reflexive analysis, and research team discussions were performed to identify and refine metanarratives. FINDINGS: Five metanarratives were identified, including the concept of trauma, the trauma event, the person with trauma, the impact of trauma, and addressing trauma, with each metanarrative encompassing multiple dimensions. A biomedical concept of trauma predominated, with lack of conceptual clarity. Theory was not integrated or developed in the majority of articles reviewed, and context was often ambiguous. Trauma was described in myriad ways among studies. Why certain events were experienced as trauma and the context in which they took place were not well characterized. The impact of trauma was largely concentrated on harmful effects, and manifestations beyond symptoms of post-traumatic stress were often not considered. Furthermore, the dominant focus was on the individual, yet often in a circumscribed way that did not seek to understand the individual experience. In addressing trauma, recommendations were often generic, and earlier research emphasized individually-focused interventions while more recent studies have considered systemic issues. INSIGHTS: Multiple dimensions of trauma have been discussed in the medical education literature and from many conceptual standpoints, with biomedical, epidemiologic, and individualized perspectives predominating. Greater precision and clarity in defining and understanding trauma is needed to advance research and theory around trauma in medical education and the associated implications for practice. Exploring trauma from intersectional and collective experiences and impacts of trauma and adapting responses to individual needs offers ways to deepen our understanding of how to better support learners impacted by trauma.

The initial validation of an Evidence-informed, competency-based, Applied Compassion Training (EnACT) program: a multimethod study.

INTRODUCTION: Compassion is positively associated with improved patient outcomes, quality care ratings, and healthcare provider wellbeing. Supporting and cultivating healthcare providers' compassion through robust and meaningful educational initiatives has been impeded by a lack of conceptual clarity, inadequate content coverage across the domains of compassion, and the lack of validated evaluation tools. The EnACT program aims to address these gaps through an Evidence-informed, competency-based, Applied, Compassion Training program delivered to healthcare providers working in various clinical settings. In this study, we describe the development and initial validation of the program, which will inform and be further evaluated in a forthcoming Randomised Controlled feasibility Trial (RCfT). METHOD: A multimethod design was used to explore learner needs, experiences, and outcomes associated with the program. Pre- and post-training surveys and qualitative interviews (1 month post training) were conducted among twenty-six healthcare provider learners working in acute care and hospice. Quantitative measures assessed professional fulfillment/burnout, self-confidence in providing compassion, learner satisfaction, and compassion competence. Qualitative interviews explored learners' experiences of the program, integration of learnings into their professional practice, and program recommendations. RESULTS: Learners exhibited relatively high self-assessed compassion competence and professional fulfillment pre-training and low levels of burnout. Post-training, learners demonstrated high levels of compassion confidence and satisfaction with the training program. Despite high levels of reported compassion competence pre-training, a statistically significant increase in post-training compassion competence was noted. Thematic analysis identified five key themes associated with learners' overall experience of the training day and integration of the learnings and resources into their professional practice: (1) A beginner's mind: Learner baseline attitudes and assumptions about the necessity and feasibility of compassion training; (2) Learners' experiences of the training program; (3) Learner outcomes: integrating theory into practice; (4) Creating cultures of compassion; and (5) Learner feedback. CONCLUSION: Findings suggest that the EnACT program is a feasible, rigorous, and effective training program for enhancing healthcare provider compassion. Its evidence-based, patient-informed, clinically relevant content; interactive in class exercises; learner toolkit; along with its contextualized approach aimed at improving the clinical culture learners practice holds promise for sustaining learnings and clinical impact over time-which will be further evaluated in a Randomized Controlled feasibility Trial (RCfT).

Program Leaders' and Educators' Perspectives on the Factors Impacting the Implementation and Sustainment of Compassion Training Programs: A Qualitative Study.

PHENOMENON: Training programs have been used to improve compassion in healthcare, but the factors necessary to make such programs successful and sustainable have not been identified. This thematic analysis aimed to bridge the gap between theory and practice by drawing on the experiences of international leaders and educators of compassion training programs to develop a clear understanding of what is relevant and effective and how compassion training is implemented and sustained. APPROACH: International leaders and educators of compassion training programs (N = 15) were identified through convenience sampling based on academic and gray literature searches. Semi-structured face-to-face interviews with these participants were conducted between June 2020 and November 2020 in order to identify facilitators, barriers, and environmental conditions influencing the implementation and maintenance of compassion training programs. The interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. FINDINGS: Six categories affecting the operationalization of compassion training programs were identified 1) origins, foundational principles and purpose, 2) curricular content, 3) methods of teaching and learning, 4) trainer qualities, 5) challenges and facilitators, and 6) evaluation and impact. INSIGHTS: Compassion training should be rooted in the construct of interest and incorporate patients' needs and their experience of compassion, with patient-reported compassion scores integrated before and after training. Compassion training should be delivered by highly qualified educators who have an understanding of the challenges associated with integrating compassion into clinical practice, a dedicated contemplative practice, and a compassionate presence in the classroom. Prior to implementing compassion training, leadership support should be secured to create an ethos of compassion throughout the organization.

Approaches to interpersonal conflict in simulation debriefings: A qualitative study.

CONTEXT: Conflict during simulation debriefing can interfere with learning when psychological safety is threatened. Debriefers often feel unprepared to address conflict between learners and the literature does not provide evidence-based guidance within the simulation setting. The purpose of this study was to describe debriefers' approach to mediating interpersonal conflict and explore when, why and how they adopt mediation strategies. METHODS: We performed a secondary analysis of qualitative data collected as part of a larger study examining simulation debriefers' approaches to debriefing scenarios with different learner characteristics. For this study, we applied thematic analysis to transcripts from simulated debriefings (n = 10) and the associated pre-simulation (n = 11) and post-simulation (n = 10) interviews that focused on interpersonal conflict between learners. RESULTS: Debriefers described struggling with mediating conflict and the importance of self-awareness. Specific mediation strategies included intervening, addressing power relations, reconciling unproductive differences, leveraging different perspectives, circumventing the conflict, and shifting beyond the conflict; each of these strategies encompassed a number of particular skills. Situations that triggered a mediation approach were related to psychological safety, emotional intensity, and opportunities for shared understanding and productive learning. Debriefers applied mediation strategies and skills in a flexible and creative way. CONCLUSIONS: The strategies we have described for mediating interpersonal conflict between learners in simulation debriefing align with notions of psychological safety and may be useful in guiding future professional development for simulation educators.

What works for whom in compassion training programs offered to practicing healthcare providers: a realist review.

BACKGROUND: Patients and families want their healthcare to be delivered by healthcare providers that are both competent and compassionate. While compassion training has begun to emerge in healthcare education, there may be factors that facilitate or inhibit the uptake and implementation of training into practice. This review identified the attributes that explain the successes and/or failures of compassion training programs offered to practicing healthcare providers. METHODS: Realist review methodology for knowledge synthesis was used to consider the contexts, mechanisms (resources and reasoning), and outcomes of compassion training for practicing healthcare providers to determine what works, for whom, and in what contexts. RESULTS: Two thousand nine hundred ninety-one articles underwent title and abstract screening, 53 articles underwent full text review, and data that contributed to the development of a program theory were extracted from 45 articles. Contexts included the clinical setting, healthcare provider characteristics, current state of the healthcare system, and personal factors relevant to individual healthcare providers. Mechanisms included workplace-based programs and participatory interventions that impacted teaching, learning, and the healthcare organization. Contexts were associated with certain mechanisms to effect change in learners' attitudes, knowledge, skills and behaviors and the clinical process. CONCLUSIONS: In conclusion this realist review determined that compassion training may engender compassionate healthcare practice if it becomes a key component of the infrastructure and vision of healthcare organizations, engages institutional participation, improves leadership at all levels, adopts a multimodal approach, and uses valid measures to assess outcomes.

Compassion in the Clinical Context: Constrained, Distributed, and Adaptive.

BACKGROUND: Compassion is intrinsically situated within particular contexts and how these contexts can shape compassion has not been well-described. OBJECTIVE: The purpose of the study was to describe how individual and contextual challenges can impact compassion within critical care and palliative care settings. DESIGN: This qualitative study adopted phenomenology and autoethnography to inform data collection, and principles of activity theory and realist inquiry for data interpretation. PARTICIPANTS: Five clinicians who work in critical care (n = 3) and palliative care (n = 3) participated in the study. APPROACH: Qualitative data were obtained from ethnographic observations, interviews, and focus groups. Participants observed and recorded field notes (n = 53) on instances of suffering and compassion in their workplace settings. At the end of the study period, they participated in a focus group or individual interview to reflect on their experiences. Data was analyzed using constructivist grounded theory techniques and iteratively synthesized through group discussion and model building. KEY RESULTS: The findings reflected four phenomena associated with compassion in context: individual gaps and lapses in compassion, relational challenges, contextual constraints on compassion, and distributed compassion. Individual gaps and lapses in compassion involved inattention, intention vs. perception, personal capacity, and personal toll. Relational challenges included receptivity, fragmentation, and lack of shared understanding. Contextual constraints consisted of situational pressures, the clinical environment, gaps in education, and organizational culture. The distribution of compassion within teams and how teams adapt their behaviors in response to perceived needs for greater compassion modulated these challenges. CONCLUSIONS: The study illustrates the many ways in which compassion can be shaped by context and highlights the role of teamwork in identifying gaps and lapses in compassion and responding in a way that supports patients, families, and colleagues.

End-of-life care in patients with a highly transmissible respiratory virus: implications for COVID-19.

Symptom management and end-of-life care are core skills for all physicians, although in ordinary times many anesthesiologists have fewer occasions to use these skills. The current coronavirus disease (COVID-19) pandemic has caused significant mortality over a short time and has necessitated an increase in provision of both critical care and palliative care. For anesthesiologists deployed to units caring for patients with COVID-19, this narrative review provides guidance on conducting goals of care discussions, withdrawing life-sustaining measures, and managing distressing symptoms.

RéSUMé: La prise en charge des symptômes et les soins de fin de vie sont des compétences de base pour tous les médecins, bien qu'en temps ordinaire, de nombreux anesthésiologistes n'ont que peu d'occasions de mettre en pratique ces compétences. La pandémie actuelle de coronavirus 2019 (COVID-19) a provoqué un taux de mortalité significatif dans un court intervalle et a nécessité une augmentation des besoins en soins intensifs et en soins palliatifs. Destiné aux anesthésiologistes déployés dans les unités prenant soin de patients atteints de la COVID-19, ce compte rendu narratif offre des recommandations quant à la façon de mener les discussions à propos des objectifs de soins, du retrait des thérapies de soutien vital, et de la prise en charge de symptômes de détresse.

Outcomes of Ethics Consultations in Adult ICUs: A Systematic Review and Meta-Analysis.

OBJECTIVES: Clinical ethics consultation as a mechanism for supporting patients, family, and staff during ethically challenging situations has become standard of care. Despite this, there is a lack of consensus about the effectiveness of clinical ethics consultation consultation in the ICU. We performed a systematic review of outcomes associated with clinical ethics consultation within adult ICUs. DATA SOURCES: We searched MEDLINE, PubMed, Cochrane CENTRAL, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature from 1984 to May 2017. STUDY SELECTION: Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias using the Cochrane Collaboration Risk of Bias tool and the Newcastle-Ottawa Scale. Pooled estimates of effect were calculated where possible. We screened 3,970 abstracts and reviewed 325 full-text articles of which 16 met all eligibility criteria. DATA EXTRACTION: We examined changes in processes and outcomes as a result of clinical ethics consultation in the ICU. Categories of outcomes included user perception, clinical decision, or conflict resolution and resource utilization. DATA SYNTHESIS: The use of clinical ethics consultation in the ICU was associated with positive user experience (383/435 found clinical ethics consultation helpful), although stress and disagreement with clinical ethics consultation recommendations was greater in a subset (113/431 surrogates and providers). Consensus for a clinical decision was more frequently achieved with clinical ethics consultation (odds ratio, 4.09; 95% CI, 1.01-16.55; p = 0.05). Clinical ethics consultation was associated with lower resource utilization including significantly decreased ICU length of stay (mean difference, -4.65 d; 95% CI, -8.86 to -0.44; p = 0.03). CONCLUSIONS: Our review identified outcome-based assessment as the predominant measure used to report effectiveness of clinical ethics consultation consultations. In particular, clinical ethics consultation decreased ICU length of stay and increased family and healthcare provider satisfaction. However, using outcome measures as the primary endpoint may not reflect the original intent of the clinical ethics consultation service. Based on our review, we propose a list of process measures that may better capture the key domains of a quality clinical ethics consultation.

A Multicenter Observational Study of Family Participation in ICU Rounds.

OBJECTIVES: Guidelines recommend offering family members of critically ill patients the option to attend interdisciplinary team rounds as a way to improve communication and satisfaction. Uncertainty remains around the benefits and risks. DESIGN: We conducted an observational study to describe family participation in ICU rounds and its association with rounding processes. SETTING: Rounds conducted under the leadership of 33 attending physicians in seven hospitals across three Canadian cities. PATIENTS: Three hundred two individual rounds on 210 unique patients were observed. INTERVENTIONS: Quantitative and qualitative data were collected using standardized observational tools. MEASUREMENTS AND MAIN RESULTS: Among the 302 rounds observed, family attended in 68 rounds (23%), were present in ICU but did not attend in 59 rounds (20%), and were absent from the ICU in 175 rounds (58%). The median duration of rounds respectively for these three groups of patients was 20 minutes (interquartile range, 14-26 min), 16 minutes (interquartile range, 13-22 min), and 16 minutes (interquartile range, 10-23 min) (p = 0.01). There were no significant differences in prognostic discussions (35% vs 36% vs 36%; p = 0.99) or bedside teaching (35% vs 37% vs 34%; p = 0.88). The quality of rounds was not significantly associated with family attendance in rounds or presence in the ICU (quality score [1 (low) to 10 (high)] median 8 [interquartile range, 7-8] vs 7 [interquartile range, 6-9] vs 7 [interquartile range, 6-9]; p = 0.11). Qualitative analyses suggested that family attendance may influence relationship building, information gathering, patient and family education, team dynamics, future family meetings, workflow, and shared clinical decision-making. CONCLUSIONS: Our results suggest family attendance in ICU rounds is associated with longer duration of rounds, but not the frequency of trainee teaching, discussions of prognosis, or quality of rounds. Family attendance in rounds may enhance communication and complement family conferences.

Goals of care conversation teaching in residency - a cross-sectional survey of postgraduate program directors.

BACKGROUND: Residents are commonly involved in establishing goals of care for hospitalized patients. While education can improve the quality of these conversations, whether and how postgraduate training programs integrate such teaching into their curricula is not well established. The objective of this study was to characterize perceptions of current teaching and assessment of goals of care conversations, and program director interest in associated curricular integration. METHODS: An electronic survey was sent to all postgraduate program directors at the University of Calgary. Quantitative data was analyzed using descriptive statistics and qualitative comments were analyzed using thematic analysis. RESULTS: The survey response rate was 34% (22/64). Formal goals of care conversation teaching is incorporated into 63% of responding programs, and most commonly involves lectures. Informal teaching occurs in 86% of programs, involving discussion, direct observation and role modeling in the clinical setting. Seventy-three percent of programs assess goals of care conversation skills, mostly in the clinical setting through feedback. Program directors believe that over two-thirds of clinical faculty are prepared to teach goals of care conversations, and are interested in resources to teach and assess goals of care conversations. Themes that emerged include 1) general perceptions, 2) need for teaching, 3) ideas for teaching, and 4) assessment of goals of care conversations. CONCLUSIONS: The majority of residency training programs at the University of Calgary incorporate some goals of care conversation teaching and assessment into their curricula. Program directors are interested in resources to improve teaching and assessment of goals of care conversations.

An exploration of contextual dimensions impacting goals of care conversations in postgraduate medical education.

BACKGROUND: Postgraduate medical trainees are not well prepared difficult conversations about goals of care with patients and families in the acute care clinical setting. While contextual nuances within the workplace can impact communication, research to date has largely focused on individual communication skills. Our objective was to explore contextual factors that influence conversations between trainees and patients/families about goals of care in the acute care setting. METHODS: We conducted an exploratory qualitative study involving five focus groups with Internal Medicine trainees (n = 20) and a series of interviews with clinical faculty (n = 11) within a single Canadian centre. Thematic framework analysis was applied to categorize the data and identify themes and subthemes. RESULTS: Challenges and factors enabling goals of care conversations emerged within individual, interpersonal and system dimensions. Challenges included inadequate preparation for these conversations, disconnection between trainees, faculty and patients, policies around documentation, the structure of postgraduate medical education, and resource limitations; these challenges led to missed opportunities, uncertainty and emotional distress. Enabling factors were awareness of the importance of goals of care conversations, support in these discussions, collaboration with colleagues, and educational initiatives enabling skill development; these factors have resulted in learning, appreciation, and an established foundation for future educational initiatives. CONCLUSIONS: Contextual factors impact how postgraduate medical trainees communicate with patients/families about goals of care. Attention to individual, interpersonal and system-related factors will be important in designing educational programs that help trainees develop the capacities needed for challenging conversations.

Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers.

BACKGROUND: Communication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers. METHODS: A cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions. RESULTS: Of the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37%), including 272 of 512 nurses (53%), 153 of 484 internal medicine trainees (32%), and 43 of 260 attending physicians (17%). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making. CONCLUSIONS: Translating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care.

Exploring the value of structured narrative feedback within the Serious Illness Conversation-Evaluation Exercise (SIC-Ex): a qualitative analysis.

OBJECTIVES: The Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics. DESIGN: Qualitative study using template analysis. SETTING: Three academic cancer centres in Canada. PARTICIPANTS: 7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists. INTERVENTIONS: Each trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters' narrative comments and identify themes/subthemes. OUTCOME MEASURES: How narrative comments aligned with elements of the CCG and SICG. RESULTS: Template analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG. CONCLUSIONS: Narrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees' competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.

Acceptability of the Venting Wisely pathway for use in critically ill adults with hypoxaemic respiratory failure and acute respiratory distress syndrome (ARDS): a qualitative study protocol.

INTRODUCTION: Hypoxaemic respiratory failure (HRF) affects nearly 15% of critically ill adults admitted to an intensive care unit (ICU). An evidence-based, stakeholder-informed multidisciplinary care pathway (Venting Wisely) was created to standardise the diagnosis and management of patients with HRF and acute respiratory distress syndrome. Successful adherence to the pathway requires a coordinated team-based approach by the clinician team. The overall aim of this study is to describe the acceptability of the Venting Wisely pathway among critical care clinicians. Specifically, this will allow us to (1) better understand the user's experience with the intervention and (2) determine if the intervention was delivered as intended. METHODS AND ANALYSIS: This qualitative study will conduct focus groups with nurse practitioners, physicians, registered nurses and registered respiratory therapists from 17 Alberta ICUs. We will use template analysis to describe the acceptability of a multicomponent care pathway according to seven constructs of acceptability: (1) affective attitude;,(2) burden, (3) ethicality, (4) intervention coherence, (5) opportunity costs, (6) perceived effectiveness and (7) self-efficacy. This study will contribute to a better understanding of the acceptability of the Venting Wisely pathway. Identification of areas of poor acceptability will be used to refine the pathway and implementation strategies as ways to improve adherence to the pathway and promote its sustainability. ETHICS AND DISSEMINATION: The study was approved by the University of Calgary Conjoint Health Research Ethics Board. The results will be submitted for publication in a peer-reviewed journal and presented at a scientific conference. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04744298.

Evaluating transformative health leadership education for Indigenous health: a mixed methods study.

BACKGROUND: There is an urgent need to improve structural competency and anti-racism education across health systems. Many leaders in health systems have the ability and responsibility to play a significant role in policy change and transforming healthcare delivery to address health inequities and injustices. The aim of this project was to evaluate a new health leadership Indigenous health course: PLUS4I. METHODS: A mixed methods design grounded in a pragmatic paradigm was used. Attendees to the first four cohorts (n=75) were sent an invitation to complete a survey evaluating their learning immediately after the completion of PLUS4I. We retrospectively collected self-efficacy ratings from participants who were also invited to participate in a semi-structured interview about their experience in PLUS4I. Descriptive statistical analysis was conducted for the quantitative assessment of the survey data. A qualitative descriptive approach to thematic analysis was used for the qualitative interview data. RESULTS: A total of 45 completed quantitative evaluations (n=45) were completed across all four cohorts. Paired t-tests were used to show pre-changes and post-changes in self-reported confidence on a 6-point Likert scale across four categories of activities. Improvements were seen in the ratings across all categories of activities, and all were statistically significant (p<0.001). Two overarching themes emerged from the qualitative analysis: breaking down previous knowledge and critical applications; building new knowledge and change-making competencies. The qualitative interviews (n=25) averaged 32:23 min, with 18 female (72%) and 7 male (28%) interview participants. CONCLUSION: Future work will support expansion of the PLUS4I course into other work environments and faculties, where the learning environment, structure and relevant Truth and Reconciliation Calls to Action may be different. This work responds to the urgent need to create systems-level change to address structural racism and implement high-quality Indigenous health and anti-racism education.

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.

Late Stent Thrombosis in a Patient with Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

Blunt thoracic aortic injury (BTAI) is associated with high mortality and morbidity. Thoracic endovascular aortic repair has become the recommended treatment modality given improved short-term results compared to open repair. We present a case of a 19-year-old male who presented with acute paralysis and multiorgan dysfunction from acute TEVAR thrombosis. Systemic thrombolysis, catheter-directed thrombolysis followed by aspiration thrombectomy, and angioplasty were initially successful in restoring perfusion. However, he developed progressive multiorgan failure related to prompt reocclusion within 48 hours. This case is the first to describe thrombolysis and angioplasty as a management strategy for acute TEVAR thrombosis. We also review the literature surrounding this uncommon complication.