May 2015 Really Good Stuff | A Journal Club Review – Tips for promoting professional identity development

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e-Editor Intern’s note:  The following is a scholarly review of several articles found in our Really Good Stuff section of this month’s edition.  We thank Carey & Megan for their thoughtful review. – TC

By Carey Mather & Megan Quentin-Baxter

Four short papers appearing in the May issue of Medical Education focus on a constructivist learning approach and personal accountability to develop appropriate professional behaviours and identity. The first three are relatively low cost interventions using existing tools or infrastructure in new, authentic ways, minimising the impact on staff, and explicitly recognising the challenges of an overcrowded curricula. The fourth builds on establishing a safe environment for ‘raising concerns’. The tools provide students with mechanisms for bridging between theory and experiential learning environments, and promoting the development of ‘agency’.(1)

‘Off to a good start’(2) describes medical student orientation to “highlight the central role of physician-patient relationship on the first morning of the first day” and teasing out the reasons why students chose this profession. This sharing forms a platform for an on-going relationship with the programme educators and peers and promotes “facilitating transition into the medical profession”. The researchers claimed that the “profoundly moving stories that emerge not only help each student calibrate their individual moral compass … also serve as an important team building experience”. One student said that it “set an inspirational tone” and the researchers found “professional identity that embraces inquisitive and altruistic professional behaviour” consistent with theories elsewhere.(3)

‘Using Twitter to teach problem based learning’(4) harnessed an emerging social media technology as a useful adjunct for a crowded curricula to “use an innovative approach to optimise the method in which we delivered PBL tutorials.” This innovation minimised impact on student and staff time because participants could post or review the microblogs asynchronously outside scheduled tutorials. It enabled connectivity within the group even though they only met intermittently.(5) Identifying the learning objectives and answering simple questions as they arose enabled more complex interactions during tutorials. Despite staff using the same ‘tutor’ account students indicated they developed rapport with staff members. This strategy also promoted a learner-centred approach that is reshaping pedagogy.(6)

The ‘Professional competencies toolkit: Teaching reflection with flash cards’(7) project sent students into clinical experience every two weeks with at least one of 28 flash cards defining a topic (such as ‘the invisible patient’) and tasks and tips for dealing with it to promote concepts that define habitual professionalism. The flash card/aide memoire provided a specific hook to remind students to collect evidence to facilitate subsequent reflection. This process encouraged to students to bring “their story back to the group” for further discussion in small group settings. The authors claim that encouraging students to focus on “manageable learning “bites” or ”one or two basic elements” promoted a level of reflection leading to “deep understanding of the importance and complexity of the broader issue.” reflecting the early stages of theoretical concepts of Fink’s ‘significant learning’.(8)

Concerns about raising concerns’(9) described an environment based on (10) responding to the UK’s Francis Report (11) where dental students were encouraged to “explore their understanding and beliefs regarding professional behaviours” in workshops, annual learning agreements, lectures and final year seminars. New policies and practices (many escalating externally to the school) were put in place to ensure “visibly fair and effective” actions arising from student’s views. The authors observed that students raised “significantly” far more concerns about “themselves, colleagues and staff” than were expected.

In all the use of narrative and communication inform professional identity and promote rapport development with teachers, students or patients. Collaborative, interactive team-building strategies were used to model and explore the central themes, with a common outcome of increased collaboration or connectivity between students, staff or patients. Communication processes were orientated towards relationship-building and increase of rapport to support patient-centred care and habituate professional behaviours.

These approaches give students an opportunity to contribute through articulation of self and their experiences. The student role is elevated to co-creator of knowledge, co-owner of responsibility, and students provided with real opportunities to contribute to patient safety and care.

Collectively these novel approaches could be tailored to other healthcare programmes to foster professional behaviours and student accountability. It would be interesting to hear from institutions using similar or a mixture of methods to promote professional identity development of students.

References

  1. Billett S. Relational interdependence between social and individual agency in work and working life. Mind, Culture, and Activity 2006;13(1):53-69.
  2. Danoff A, Garabedian M, Harnik V, Rosenthal M. Off to a good start. Medical Education 2015;49(5):514.
  3. Stern DT. Measuring Medical Professionalism. New York: Oxford University Press 2006.
  4. Lasker R, Vicneswararajah N.. Using Twitter to teach problem-based learning. Medical Education 2015;49(5):531.
  5. Kamel Boulos MN, Wheeler S. The emerging Web 2.0 social software: an enabling suite of sociable technologies in health and healthcare education. Health Information and Libraries Journal 2007;24(1):2-23.
  6. Caplan W, Myrick F, Smitten J, Kelly W. What a tangled web we weave: How technology is reshaping pedagogy. Nurse Education Today 2014;34(8):1172-4.
  7. Seymour P, Watt M. The professional competencies toolkit: teaching reflection with flash cards. Medical Education 2015;49(5):518.
  8. Fink LD. Creating Significant Learning Experiences: An Integrated Approach to Designing College Courses. Jossey-Bass 2003.
  9. Ellis JS, Bateman H, Thomason JM, Whitworth J. Concerns about raising concerns. Medical Education 2015;49(5):514-5.
  10. Kelly M, O’Flynn S, McLachlan JC, Sawdon MA. The clinical conscientiousness index: a valid tool for exploring professionalism in the clinical undergraduate setting. Academic Medicine 2012;87(9):1218-24.
  11. The Mid Staffordshire NHS Foundation Trust. Public Inquiry Chaired by Robert Francis QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 3 vols. London: Stationery Office 2013.

Conversation Kickstarter | Feedback and the learner

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by Teresa Chan, MD, FRCPC
e-Editor intern, Assistant Professor, McMaster University

In this month’s upcoming issue of The Clinical Teacher, David Boud writes a commissioned paper that provides us with helpful tips and hints regarding feedback.  This article is most definitely a ‘go to’ resource for any health professional who teaches in the clinical setting.

As he highlights in the article,”… [f]eedback in clinical settings, must be characterised
not solely in terms of inputs, but also by the effects that result.”  Particularly, this concept hit home for me.  You see, for the past few years I’ve been hard at work at my institution working with our residency education program to redesign workplace based assessment to emphasize feedback.  This has resulted in the McMaster Modular Assessment Program, and I must say, even after all of the literature I’ve read, Dr. Boud’s paper really synthesized and summarized some really pragmatic tips that I will be taking to the bedside.

As a learner, I was always the pesky learner that asked for feedback… and I recall being quite aggressive in asking for specific ways to improve my burgeoning practice.  Now, as a junior clinician educator that is interested in assessment and feedback, I have lived my life with trying to figure out how to best design a system that creates the opportunities for residents to do the same.

At times, I worry that by being too much of an educational designer, I am removing the agency from the learner, and decreasing the impetus for them to self-direct this feedback. Recently, I have read the book by Stone & Heen which emphasizes the key skill of receiving feedback well (Thanks for the Feedback: The Science and Art of Receiving Feedback Well).

And so, I am wondering if I might engage The Clinical Teacher audience in a discussion around the idea of feedback using these three questions:

  • Q1: Are we ‘babying’ learners these days too much by creating systems that encourage feedback?
  • Q2: Or does the system need to be there to provide a scaffold for learners so that they might one day more fully participate in the feedback experience?
  • Q3: Ultimately, what is the role of the adult health professions learner in the feedback process?

Please drop a line below to reply to these questions (and be sure to mark which question you’re answering using Q1/Q2/Q3).  Feel free to tweet around this using the hashtag #ClinTeach.

Portrait of a rural health graduate: exploring alternative learning spaces

By Andrew Ross and Daisy Pillay

Link to article here.

Context

Given that the staffing of rural facilities represents an international challenge, the support, training and development of students of rural origin at institutions of higher learning (IHLs) should be an integral dimension of health care provisioning. International studies have shown these students to be more likely than students of urban origin to return to work in rural areas. However, the crisis in formal school education in some countries, such as South Africa, means that rural students with the capacity to pursue careers in health care are least likely to access the necessary training at an IHL. In addition to challenges of access, throughput is relatively low at IHLs and is determined by a range of learning experiences. Insight into the storied educational experiences of health care professionals (HCPs) of rural origin has the potential to inform the training and development of rural-origin students.

Methods

Six HCPs of rural origin were purposively selected. Using a narrative inquiry approach, data were generated from long interviews and a range of arts-based methods to create and reconstruct the storied narratives of the six participants. Codes, categories and themes were developed from the reconstructed stories. Reid’s four-quadrant model of learning theory was used to focus on the learning experiences of one participant.

Results

Alternative learning spaces were identified, which were made available through particular social spaces outwith formal lecture rooms. These offered opportunities for collaboration and for the reconfiguring of the participants’ agency to be, think and act differently. Through the practices enacted in particular learning spaces, relationships of caring, sharing, motivating and mentoring were formed, which contributed to personal, social, academic and professional development and success.

Conclusions

Learning spaces outwith the formal lecture theatre are critical to the acquisition of good clinical skills and knowledge in the development of socially accountable HCPs of rural origin.

Article first published online: 28 APR 2015 | DOI: 10.1111/medu.12676

The impact of programmatic assessment on student learning: theory versus practice

By Sylvia Heeneman, Andrea Oudkerk Pool, Lambert W T Schuwirth, Cees P M van der Vleuten and Erik W Driessen

Link to article here.

Context

It is widely acknowledged that assessment can affect student learning. In recent years, attention has been called to ‘programmatic assessment’, which is intended to optimise both learning functions and decision functions at the programme level of assessment, rather than according to individual methods of assessment. Although the concept is attractive, little research into its intended effects on students and their learning has been conducted.

Objectives

This study investigated the elements of programmatic assessment that students perceived as supporting or inhibiting learning, and the factors that influenced the active construction of their learning.

Methods

The study was conducted in a graduate-entry medical school that implemented programmatic assessment. Thus, all assessment information, feedback and reflective activities were combined into a comprehensive, holistic programme of assessment. We used a qualitative approach and interviewed students (n = 17) in the pre-clinical phase of the programme about their perceptions of programmatic assessment and learning approaches. Data were scrutinised using theory-based thematic analysis.

Results

Elements from the comprehensive programme of assessment, such as feedback, portfolios, assessments and assignments, were found to have both supporting and inhibiting effects on learning. These supporting and inhibiting elements influenced students’ construction of learning. Findings showed that: (i) students perceived formative assessment as summative; (ii) programmatic assessment was an important trigger for learning, and (iii) the portfolio’s reflective activities were appreciated for their generation of knowledge, the lessons drawn from feedback, and the opportunities for follow-up. Some students, however, were less appreciative of reflective activities. For these students, the elements perceived as inhibiting seemed to dominate the learning response.

Conclusions

The active participation of learners in their own learning is possible when learning is supported by programmatic assessment. Certain features of the comprehensive programme of assessment were found to influence student learning, and this influence can either support or inhibit students’ learning responses.

Article first published online: 28 APR 2015 | DOI: 10.1111/medu.12645

The impact of adopting EHRs: how losing connectivity affects clinical reasoning

By Lara Varpio, Kathy Day, Pat Elliot-Miller, James W King, Craig Kuziemsky, Avi Parush, Tyson Roffey and Judy Rashotte

Link to article here.

Context

As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development.

Objectives

We investigate this influence by studying clinician experiences of a hospital’s move from paper charts to an EHR. We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning?

Methods

This two-phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think-aloud (n = 13) and think-after (n = 11) sessions, interviews (n = 39) and document retrieval (n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis.

Results

In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient’s evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms.

Conclusions

Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHRs supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHRs, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity – the chronologically framed data interconnections upon which clinicians rely to provide patient care.

Article first published online: 28 APR 2015 | DOI: 10.1111/medu.12665

Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review

By Stella L Ng, Elizabeth A Kinsella, Farah Friesen and Brian Hodges

Link to article here.

Context

Reflection and reflective practice have become popular topics of scholarly dialogue in medical education. This popularity has given rise to checklists, portfolios and other tools to inspire and document reflection. We argue that some of the common ways in which reflection has been applied are influenced by broader discourses of assessment and evidence, and divorced from original theories of reflection and reflective practice.

Methods

This paper was developed using a critical narrative approach. First we present two theoretical lenses provided by theories of reflection. Next we present a summary of relevant literature, indexed in PubMed from 2004 to 2014, relating to the application of reflection or reflective practice to undergraduate and postgraduate medical education. We categorise these articles broadly by trends and problematise the trends relative to the two theoretical lenses of reflection.

Results

Two relevant theoretical orientations of reflection for medical education are: (i) reflection as epistemology of practice, and (ii) reflection as critical social inquiry. Three prevalent trends in the application of reflection to medical education are: (i) utilitarian applications of reflection; (ii) a focus on the self as the object of reflection, and (iii) reflection and assessment. These trends align with dominant epistemological positions in medicine, but not with those that underpin reflection.

Conclusions

We argue for continued theorising of and theoretically informed applications of reflection, drawing upon epistemologies of practice and critical reflection as critical social inquiry. These directions offer medical education research broad and deep potential in theories of reflection, particularly in relation to knowledge creation within uncertain and complex situations, and challenging of dominant discourses and structures. Future work could explore how dominant epistemological positions and discourses in medicine influence theories from other disciplines when these theories are deployed in medical education.

Article first published online: 28 APR 2015 | DOI: 10.1111/medu.12680

#MedEdJ | Medical Education Journal Club Returns!

At the end of this month we will be having one of our #MedEdJ virtual journal clubs. Below are the questions we are posing about the article featured in April 2015’s edition of Medical Education entitled:

‘Sorry, I meant the patient’s left side’: impact of distraction on left–right discrimination (pages 427–435)
John McKinley, Martin Dempster and Gerard J Gormley
Article first published online: 20 MAR 2015 | DOI: 10.1111/medu.12658

R-L-Error

Image provided via Creative Commons by Dr. Gerry Gormley.

This article looks at left / right confusion by medical students, using a neuropsychological paradigm.  As Dr. Gerry Gormley often asks when talking about this topic: “What is the fuss about right left confusion? Surely everyone can tell R from L?”

Specifically, this can be really important for patient care.  Remember, most procedures and surgeries will be on a single pathologic side (e.g. a Thoracocentesis), so for patient safety it can be important to identify the correct side.  Errors in such identification have lead to poor patient outcomes.

In this article, the authors explore issues such as:

  • Why are some individuals are more challenged in distinguishing right from left?

Link to the article here.

The publisher has made this article available for reading even if you don’t have a subscription to the journal.

***

This month, we have decided to create some guiding questions to help our readers think about the article.  Below are some questions compiled by our e-council and avid readers.

How this #MedEdJ Virtual Journal Club will work:

Similar to previous journal clubs for Medical Education, we invite you, the participants, to answer the questions in the blog comments below (just write Q1, Q2, Q3… etc.. to denote your answers).

Then starting on May 1, 2015, members of the authorship team will be online to respond.  We will have a live Tweet Chat on May 1, 2015 with one of the authors (Dr. Gerry Gormley, @DrGerryG) from 3-4pm British Standard Time (10am-11am Eastern Daylight Time; 7am-8am Pacific Standard Time).

During the Tweet Chat, we will use the hashtag #MedEdJ.

After that, you can continue to comment on the areas below and we will help facilitate answers and discussion with the authors via the blog.

Questions:

  1. Is there any evidence about the best way to improve left/right discrimination?
  2. Should medical schools be screening students for LR discrimination ability? And if so what impact would that information have on you?
  3. How is your medical school going to help students improve their left/right discrimination and deal with distraction?
  4. Is your medical school considering helping students to deal with distraction in medical practice generally?
  5. Given that distraction management is also a function of attentional control, would it have been helpful for the authors to measure working memory?
  6. How would their conclusions about sex and L/R distraction have changed if they had measured visual spatial intelligence and working memory capacity?

Don’t be shy!  Join into the conversation below!  All answers are welcome!

Acknowledgements:

Thanks to Kulamakan Kulasegaram, Ellie Hothersall, and Karen Scott for their contributions to these questions.

Exploring the impact of workplace cyberbullying on trainee doctors

By Samuel Farley, Iain Coyne, Christine Sprigg, Carolyn Axtell and Ganesh Subramanian.

Link to article here.

Objectives

Workplace bullying is an occupational hazard for trainee doctors. However, little is known about their experiences of cyberbullying at work. This study examines the impact of cyberbullying among trainee doctors, and how attributions of blame for cyberbullying influence individual and work-related outcomes.

Methods

Doctors at over 6 months into training were asked to complete an online survey that included measures of cyberbullying, blame attribution, negative emotion, job satisfaction, interactional justice and mental strain. A total of 158 trainee doctors (104 women, 54 men) completed the survey.

Results

Overall, 73 (46.2%) respondents had experienced at least one act of cyberbullying. Cyberbullying adversely impacted on job satisfaction (β = − 0.19; p < 0.05) and mental strain (β = 0.22; p < 0.001), although attributions of blame for the cyberbullying influenced its impact and the path of mediation. Negative emotion mediated the relationship between self-blame for a cyber-bullying act and mental strain, whereas interactional injustice mediated the association between blaming the perpetrator and job dissatisfaction.

Conclusions

Acts of cyberbullying had been experienced by nearly half of the sample during their training and were found to significantly relate to ill health and job dissatisfaction. The deleterious impact of cyberbullying can be addressed through both workplace policies, and training for trainee doctors and experienced medical professionals.

DOI: 10.1111/medu.12666

‘Sorry, I meant the patient’s left side’: impact of distraction on left–right discrimination

By John McKinley, Martin Dempster and Gerard J Gormley

Link to article here.

Context

Medical students can have difficulty in distinguishing left from right. Many infamous medical errors have occurred when a procedure has been performed on the wrong side, such as in the removal of the wrong kidney. Clinicians encounter many distractions during their work. There is limited information on how these affect performance.

Objectives

Using a neuropsychological paradigm, we aim to elucidate the impacts of different types of distraction on left–right (LR) discrimination ability.

Methods

Medical students were recruited to a study with four arms: (i) control arm (no distraction); (ii) auditory distraction arm (continuous ambient ward noise); (iii) cognitive distraction arm (interruptions with clinical cognitive tasks), and (iv) auditory and cognitive distraction arm. Participants’ LR discrimination ability was measured using the validated Bergen Left–Right Discrimination Test (BLRDT). Multivariate analysis of variance was used to analyse the impacts of the different forms of distraction on participants’ performance on the BLRDT. Additional analyses looked at effects of demographics on performance and correlated participants’ self-perceived LR discrimination ability and their actual performance.

Results

A total of 234 students were recruited. Cognitive distraction had a greater negative impact on BLRDT performance than auditory distraction. Combined auditory and cognitive distraction had a negative impact on performance, but only in the most difficult LR task was this negative impact found to be significantly greater than that of cognitive distraction alone. There was a significant medium-sized correlation between perceived LR discrimination ability and actual overall BLRDT performance.

Conclusions

Distraction has a significant impact on performance and multifaceted approaches are required to reduce LR errors. Educationally, greater emphasis on the linking of theory and clinical application is required to support patient safety and human factor training in medical school curricula. Distraction has the potential to impair an individual’s ability to make accurate LR decisions and students should be trained from undergraduate level to be mindful of this.

DOI: 10.1111/medu.12658

The struggling student: a thematic analysis from the self-regulated learning perspective

By Rakesh Patel, Carolyn Tarrant, Sheila Bonas, Janet Yates and John Sandars

Link to article here.

Context

Students who engage in self-regulated learning (SRL) are more likely to achieve academic success compared with students who have deficits in SRL and tend to struggle with academic performance. Understanding how poor SRL affects the response to failure at assessment will inform the development of better remediation.

Methods

Semi-structured interviews were conducted with 55 students who had failed the final re-sit assessment at two medical schools in the UK to explore their use of SRL processes. A thematic analysis approach was used to identify the factors, from an SRL perspective, that prevented students from appropriately and adaptively overcoming failure, and confined them to a cycle of recurrent failure.

Results

Struggling students did not utilise key SRL processes, which caused them to make inappropriate choices of learning strategies for written and clinical formats of assessment, and to use maladaptive strategies for coping with failure. Their normalisation of the experience and external attribution of failure represented barriers to their taking up of formal support and seeking informal help from peers.

Conclusions

This study identified that struggling students had problems with SRL, which caused them to enter a cycle of failure as a result of their limited attempts to access formal and informal support. Implications for how medical schools can create a culture that supports the seeking of help and the development of SRL, and improves remediation for struggling students, are discussed.

DOI: 10.1111/medu.12651

How do surgeons think they learn about communication? A qualitative study

By Nicola Mendick, Bridget Young, Christopher Holcombe and Peter Salmon

Link to article here.

Context

Communication education has become integral to pre- and post-qualification clinical curricula, but it is not informed by research into how practitioners think that good communication arises.

Objectives

This study was conducted to explore how surgeons conceptualise their communication with patients with breast cancer in order to inform the design and delivery of communication curricula.

Methods

We carried out 19 interviews with eight breast surgeons. Each interview centred on a specific consultation with a different patient. We analysed the transcripts of the surgeons’ interviews qualitatively using a constant comparative approach.

Results

All of the surgeons described communication as central to their role. Communication could be learned to some extent, not from formal training, but by selectively incorporating practices they observed in other practitioners and by being mindful in consultations. Surgeons explained that their own values and character shaped how they communicated and what they wanted to achieve, and constrained what could be learned.

Conclusions

These surgeons’ understanding of communication is consistent with recent suggestions that communication education: (i) should place practitioners’ goals at its centre, and (ii) might be enhanced by approaches that support ‘mindful’ practice. By contrast, surgeons’ understanding diverged markedly from the current emphasis on ‘communication skills’. Research that explores practitioners’ perspectives might help educators to design communication curricula that engage practitioners by seeking to enhance their own ways of learning about communication.

DOI: 10.1111/medu.12648