How residents learn: qualitative evidence for the pivotal role of clinical activities

OBJECTIVES: Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace. METHODS: We carried out a qualitative study using focus groups. A grounded theory approach was used to analyse the transcribed tape recordings. A total of 51 obstetrics and gynaecology residents from teaching hospitals and affiliated general hospitals participated in 7 focus group discussions. Participants discussed how they learn and what factors influence their learning. RESULTS: An underlying theoretical framework emerged from the data, which clarified what happens when residents learn by doing in the clinical workplace. This framework shows that work-related activities are the starting point for learning. The subsequent processes of 'interpretation' and 'construction of meaning' lead to refinement and expansion of residents' knowledge and skills. Interaction plays an important role in the learning process. This is in line with both cognitivist and sociocultural views on learning. CONCLUSIONS: The presented theoretical framework of residents' learning provides much needed empirical evidence for the actual learning processes of residents in the clinical workplace. The insights it offers can be used to exploit the full educational potential of the clinical workplace.     

How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting

INTRODUCTION: The supervision of medical residents is a key responsibility of attending doctors in the clinical setting. Most attending doctors, however, are unfamiliar with the principles of effective supervision. Although inconsistent, supervision has been shown to be both important and effective for the professional development of medical residents. OBJECTIVE: To examine how medical residents perceive the supervisory roles of attending doctors, in terms of what they perceive as poor supervision and what they characterise as good supervisory practice. METHOD: We carried out a questionnaire survey of 38 medical residents at the Department of Paediatrics at the teaching hospital of the University of Amsterdam, the Netherlands. Attending doctors directly involved with the supervision of medical residents participated in the study. The clinical settings where supervision occurred included the neonatal and paediatric intensive care units and the general paediatric wards. RESULTS: Medical residents rated the quality of supervision they received in all departments positively. A majority of the attending doctors were rated highly in 'overall supervision'. Creating pleasant learning environments and being stimulated to learn and function independently were aspects of supervision characterised positively. Coaching in clinical skills and procedures, effective communication skills and clinical decision making using principles of cost-appropriate care were aspects of supervision found to be deficient. DISCUSSION: This study shows that medical residents enjoy supervision from collaborative, understanding and patient attending doctors. Medical residents prefer to be treated as adult learners and enjoy feedback that is constructive, measured and adapted to their professional needs.     

The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students

INTRODUCTION: Much of undergraduate clinical teaching is provided by residents. An earlier study showed the attitude of residents towards teaching to be generally positive. Little is known, however, about attending doctors' views on their own and residents' roles as teachers of medical students. OBJECTIVES: To examine attending doctors' perceptions of the (dis)advantages of resident teaching, their own teaching abilities and the need for a teacher training programme for residents. METHOD: A questionnaire survey of 76 attending doctors was carried out in the Departments of Obstetrics & Gynaecology and Paediatrics at the teaching hospitals of the Universities of Maastricht and Amsterdam, the Netherlands. RESULTS: Attending doctors perceive teaching by residents to be beneficial for students and residents alike. Although they consider themselves to be better suited than residents to teach medical students, they see teaching as an integral part of residency training and feel it should be recognised as such by departments and medical schools. Attending doctors are in favour of a teacher training programme for residents, which should include communication, clinical and teaching skills as well as skills such as time management and (self-) assessment. DISCUSSION: Despite the uneven distribution of participants between the departments, no significant differences were found between departments. It is interesting that attending doctors perceive teacher training as beneficial to residents' teaching skills, but provide more feedback on residents' attitudes than on their teaching. The results show that, in general, attending doctors share residents' views that teaching is an important component of residency and that a teacher training programme for residents is to be recommended.     

Testing an empirically derived mental health training model featuring small groups, distributed practice and patient discussion

Objectives  Internationally, family doctors seeking to enhance their skills in evidence-based mental health treatment are attending brief training workshops, despite clear evidence in the literature that short-term, massed formats are not likely to improve skills in this complex area. Reviews of the educational literature suggest that an optimal model of training would incorporate distributed practice techniques; repeated practice over a lengthy time period, small-group interactive learning, mentoring relationships, skills-based training and an ongoing discussion of actual patients. This study investigates the potential role of group-based training incorporating multiple aspects of good pedagogy for training doctors in basic competencies in brief cognitive behaviour therapy (BCBT).
Methods  Six groups of family doctors ( n  = 32) completed eight 2-hour sessions of BCBT group training over a 6-month period. A baseline control design was utilised with pre- and post-training measures of doctors' BCBT skills, knowledge and engagement in BCBT treatment.
Results  Family doctors' knowledge, skills in and actual use of BCBT with patients improved significantly over the course of training compared with the control period.
Conclusions  This research demonstrates preliminary support for the efficacy of an empirically derived group training model for family doctors. Brief CBT group-based training could prove to be an effective and viable model for future doctor training.     

The development of medical teachers: an enquiry into the learning histories of 10 experienced medical teachers

AIM: The aim of the study was to explore the different ways in which doctors have learned to teach and train. INTRODUCTION: There is no coherent theory of medical teacher development. Doctors are experts in what they teach; most have had little or no training in how they teach. Research has mostly concentrated on the acquisition and improvement of pedagogical skills by attendance at formal, generally short courses. These may have limited impact. METHODS: We carried out semistructured interviews with 10 experienced medical teachers. A review of the literature had suggested areas to explore. Interviews were transcribed and coded and thematic analysis and grounded theory used as the framework for qualitative analysis. RESULTS: Four areas were identified as important in teacher development: acquisition of educational knowledge and skills; modelling and practice of teaching skills; encouragement and motivation of teachers, and constraints on teaching and learning. DISCUSSION: The results suggest a model for teacher development that begins with doctors as learners, learning to learn and watching teachers teach. They then start to teach, acquiring and practising skills, and subsequently move on to reflect on their teaching. They can be encouraged to teach but may also be prevented from teaching. CONCLUSIONS: This inductive study proposes a model for medical teacher development that attempts to explain how doctors learn to teach and train. More research is needed to clarify the findings. There are implications for faculty development.     

Portfolio learning for foundation doctors: early feedback on its use in the clinical workplace

CONTEXT: A learning portfolio was developed to support the development of trainee doctors piloting Foundation Programme prototypes across the Northern Deanery in 2004 and 2005. Trainee doctors and their educational supervisors were surveyed about their experiences of using the portfolio in the clinical workplace. METHODS: The evaluation consisted of semi-structured interviews with trainee doctors and supervisors, followed by postal questionnaire surveys in 2004 and 2005. Quantitative and qualitative data were triangulated to identify core findings. RESULTS: Questionnaires were returned from 182/305 (60%) trainee doctors and 104 out of 179 (58%) educational supervisors. The portfolio was felt to be a 'good idea' by 55% supervisors and 48% trainees. Trainees' perceptions of the educational value of the portfolio remained consistently low over 2 surveys and they described a sense of 'burden', whereby they identified problems in workload and usability and in gaining feedback on performance. However, positive trainee attitudes towards the portfolio were significantly correlated with greater perceived educational benefits (r = 0.855, P < 0.001). DISCUSSION: Learning portfolios are now an integral part of Foundation Programme training but this evaluation suggests that many trainee doctors and educational supervisors are yet to be convinced of their educational value. Gaining multi-source feedback, a substantial component of trainee doctors' portfolios, impacts on the wider clinical team and presents a significant challenge to trainees. Educational supervisors continued to rely on feedback from clinical colleagues, rather than portfolio evidence, to monitor trainee doctors' development. Such factors may serve to disengage trainees with the portfolio process by overshadowing any perceived educational gains.     

An inventory to improve clinical teaching in the general internal medicine clinic

The increasing occurrence of outpatient medical care has led to the need for more and better medical education in the clinic. the Wisconsin Inventory of Clinic Teaching (WICT) was developed to improve the teaching of attending doctors in a general internal medicine clinic. The items on the inventory were derived from interviews with residents and attending doctors. The inventory was shown to have validity, and to be reliable with internal consistency correlations. We found an interesting disparity between attending doctors' and residents' expectations concerning clinical teaching. The instrument is in use as part of a teaching improvement programme for attending doctors in a general internal medicine clinic.     

Organisation of workplace learning: a case study of paediatric residents’ and consultants’ beliefs and practices

Several studies have examined how doctors learn in the workplace, but research is needed linking workplace learning with the organisation of doctors’ daily work. This study examined residents’ and consultants’ attitudes and beliefs regarding workplace learning and contextual and organisational factors influencing the organisation and planning of medical specialist training. An explorative case study in three paediatric departments in Denmark including 9 days of field observations and focus group interviews with 9 consultants responsible for medical education and 16 residents. The study aimed to identify factors in work organisation facilitating and hindering residents’ learning. Data were coded through an iterative process guided by thematic analysis. Findings illustrate three main themes: (1) Learning beliefs about patient care and apprenticeship learning as inseparable in medical practice. Beliefs about training and patient care expressed in terms of training versus production caused a potential conflict. (2) Learning context. Continuity over time in tasks and care for patients is important, but continuity is challenged by the organisation of daily work routines. (3) Organisational culture and regulations were found to be encouraging as well inhibiting to a successful organisation of the work in regards to learning. Our findings stress the importance of consultants’ and residents’ beliefs about workplace learning as these agents handle the potential conflict between patient care and training of health professionals. The structuring of daily work tasks is a key factor in workplace learning as is an understanding of underlying relations and organisational culture in the clinical departments.     

The effect of in-training assessment on clinical confidence in postgraduate education

INTRODUCTION: The literature on how in-training assessment (ITA) works in practice and what educational outcomes can actually be achieved is limited. One of the aims of introducing ITA is to increase trainees' clinical confidence; this relies on the assumption that assessment drives learning through its content, format and programming. The aim of this study was to investigate the effect of introducing a structured ITA programme on junior doctors' clinical confidence. The programme was aimed at first year trainees in anaesthesiology. METHODS: The study involved a nationwide survey of junior doctors' self-confidence in clinical performance before (in 2001) and 2 years after (in 2003) the introduction of an ITA programme. Respondents indicated confidence on a 155-item questionnaire related to performance of clinical skills and tasks reflecting broad aspects of competence. A total of 23 of these items related to the ITA programme. RESULTS: The response rate was 377/531 (71%) in 2001 and 344/521 (66%) in 2003. There were no statistically significant differences in mean levels of confidence before and 2 years after the introduction of the ITA programme - neither in aspects that were related to the programme nor in those that were unrelated to the programme. DISCUSSION: This study demonstrates that the introduction of a structured ITA programme did not have any significant effect on trainees' mean level of confidence on a broad range of aspects of clinical competence. The importance of timeliness and rigorousness in the application of ITA is discussed.     

The determination of the relevance of basic sciences learning objectives to clinical practice using a questionnaire survey

OBJECTIVES: Facilitating sufficient understanding of the basic sciences to underpin clinical practice is important in producing the good doctor. However, the inclusion of irrelevant material in the curriculum not only wastes valuable learning time, but may also hinder learning. The aim of this study was to determine how relevant staff and students thought respiratory basic science learning objectives were to medical practice. DESIGN: The study involved a survey using an anonymous questionnaire to determine whether the respiratory learning objectives stated in Year 1 were perceived as relevant to clinical practice. Each learning objective was rated as being 'relevant', 'not relevant' or of 'uncertain relevance'. SETTING: Dundee Medical School, UK. SUBJECTS: Junior and senior students and staff. RESULTS: Year 1 students considered the majority of the learning objectives to be relevant to clinical practice. Staff and senior students identified some respiratory learning objectives as not relevant to clinical practice, most of which were related to biochemistry. CONCLUSIONS: The identification of learning objectives with questionable relevance to clinical practice requires careful consideration to determine whether these should be removed from the course. Attention needs to be given to both the presentation and process by which material is delivered to students. Strategies to emphasise the clinical relevance of the basic sciences to students are discussed. Further research needs to be conducted to evaluate what knowledge is essential for producing good doctors.     

Views, behaviours and perceived staff development needs of doctors and surgeons regarding learners in outpatient clinics

INTRODUCTION: The need to use outpatient clinics as a major learning environment in hospitals for students and doctors-in-training is clear. However, consultant supervisors perceive major barriers to this and continue to rely heavily on traditional inpatient learning. This quantitative study examines what approaches consultant supervisors employ in outpatient learning, together with what they perceive themselves to use and what they would value in further training. METHODS: We observed learning episodes for students and doctors-in-training in medical and surgical clinics. A questionnaire on outpatient teaching was also sent to consultant doctors and surgeons. This was based on these observations and focus groups with students and doctors-in-training. RESULTS: There was an overall survey response rate of 62% (194/311). The dominant forms of learning we observed were 'arms-length' supervision for doctors-in-training and 'modelling' for students. Only 7% of learning episodes involved a doctor-in-training doing something under direct supervision. In contrast to the observation results, consultants considered that students and doctors-in-training received a lot of direct supervision and interaction. For example, 45% considered that doctors-in-training 'may see patients with me in a joint consultation'. Only 30% of respondents would be interested in staff development in learning in outpatient clinics. CONCLUSIONS: Although consultants reported that they frequently used an active approach to learning in outpatient clinics, modelling was used predominantly for students and arms-length supervision was used for doctors-in-training.     

Contextual dynamics in clinical workplaces: learning from doctor–doctor consultations

Medical Education 2013: 47 : 463–475 CONTEXT Some studies have explored the role of learning context in clerkships and in clinical teams. Very little is known, however, about the relationship between context and competence development in more loosely framed, day‐to‐day practices such as doctor–doctor consultations, although such interactions are frequent and typical in clinical work. METHODS To address this gap in the literature, a study was conducted using semi‐structured interviews in four different hospitals and participant observation at one site. Inductive content analysis was used to develop a framework. Special reference was made to the principles of situated cognition. RESULTS The framework illustrates how different situational, personal and organisational factors interact in every learning situation. The interplay manifests in three different roles that doctors assume in highly dynamic ways: doctors learn as ‘actors’ (being responsible), as ‘participants’ (being involved) and as ‘students’ (being taught); contextual influences also impact on the quality of learning within these roles. CONCLUSIONS The findings add to the current literature on clinical workplace learning and to the conceptualisation of context in the field of education. The practical contribution of the research lies in disentangling the complex dynamics of learning in clinical environments and in helping doctors and medical educators to increase their responsiveness to contextual factors.     

Professionalism and the basic sciences: an untapped resource

CONTEXT: Medical, technological and societal developments influence doctors' professional responsibilities and present challenges to educating medical students about professionalism. Medical education about professionalism generally focuses on behaviours and competencies which are taught primarily by clinicians in clinical courses and settings. DISCUSSION: Many professional competencies in medicine parallel those in science. We consider here whether medical professionalism can also be taught through the basic science courses which often initiate medical education, and which are typically taught by scientists. CONCLUSIONS: Like doctors, basic science faculty staff can teach professional competencies to medical students. Science faculty are well situated to teach professional competencies and should do so. They can model how to pursue evidence and manage conflicting information. They can also provide explicit messages to students about professional competencies and their value, and create learning objectives that reinforce those messages.     

Perceptions of the learning environment in higher specialist training of doctors: implications for recruitment and retention

INTRODUCTION: Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention. METHODS: The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo software for qualitative data management. RESULTS: Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning. CONCLUSION: Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties.     

Martin's Map: a conceptual framework for teaching and learning the medical interview using a patient-centred approach

OBJECTIVE: At the end of training, students seem to lack a basic understanding of how to take an organised, relevant medical and social history using a patient-centred approach. The aim of developing the map described in this paper was to provide a framework for such an approach. METHODS: Action research was used to continuously modify and refine an interview map that was used by medical clerks, family medicine residents, international medical graduates and practising doctors for teaching and learning purposes over a 10-year period. CONCLUSION: 'Martin's Map' provides a realistic framework for flexibly organising and integrating medical content with process that did not previously exist. The map provides medical educators with a standardised framework for talking about the medical interview, which helps learners understand how to use their medical knowledge with a patient-centred approach. Learners are able to visually see how they can take a focused medical and social history using a patient-centred approach, which subsequently seems to help them organise their thinking and approach during the medical encounter.     

A skin cancer training programme: evaluation of a postgraduate training for family doctors

This study aimed to evaluate the effectiveness of a postgraduate skin cancer training programme in improving family doctors' levels of knowledge and clinical practice. Forty-one of 59 family doctors (69% consent) who enrolled in the training programme agreed to participate in its evaluation. Approximately half of the doctors were allocated to the 'intervention' group, and the others were in the 'waiting-list' control group. Pre- and post-test data were collected to assess changes in doctors' knowledge, perceived confidence and clinical practice. The training programme involved three sessions, including an information/education session, a practical session at the local Melanoma Unit, and a practical surgical procedures session. There were significant improvements in the proportion of (i) accurate diagnoses, which were made when lesions were presented on colour slides with an accompanying case history; (ii) lesions presented on colour slides in which the correct management of the lesion was identified; and (iii) doctors who felt very or extremely confident in their ability to advise patients on screening frequency, to advise patients on the signs of skin cancer, and to decide whether changes in lesions were malignant. The only improvement observed in the doctors' clinical practice was a significant increase from pre- to post-test in the proportion of pathology request forms on which a diagnosis of the specimen was attempted by doctors in the intervention group compared to those in the control group. The results of this study indicate that whilst significant improvements in knowledge are achievable through postgraduate programmes, clinical practice is much more difficult to change.     

Learning to doctor: tinkering with visibility in residency training

Medical doctors in teaching hospitals aim to serve the two central goals of patient care and medical training. Whereas patient care asks for experience, expertise and close supervision, medical training requires space to practise and the ‘invisibility’ of medical residents. Yet current reforms in postgraduate medical training point to an increasing emphasis on the measurable visibility of residents. Drawing on an ethnographic study of gynaecology training in The Netherlands, this article demonstrates that in daily clinical routines multiple practices of residents’ visibility (visibilities) coexist. The article lists four visibilities: staging residents, negotiating supervision, playing the invisibility game and filming surgical operations. The article shows how attending physicians and medical residents tinker with these visibilities in daily clinical work to provide good care while enacting learning space, highlighting the increasing importance of visualising technologies in clinical work. Moreover, the article contributes to traditional sociological accounts on medical education, shifting the focus from medical education as a social institution to the practices of medical training itself. Such a focus on practice helps to gain an understanding of how the current reform challenges clinicians’ educational activities.     

A survey of clinical teaching fellowships in UK medical schools

CONTEXT: Undergraduate medical education in the UK has changed considerably over the last decade. One development has involved the creation of teaching-specific posts for junior doctors by medical schools. These posts are generally termed 'clinical teaching fellowships', but it is not known how many of them exist, or whether they are similar in terms of educational activities, professional development, and research and clinical experience opportunities. METHODS: Teaching deans in all UK medical schools were sent a questionnaire relating to clinical teaching fellowships, and were asked to distribute a second set of different questionnaires to their clinical teaching fellows, which were to be returned to the authors separately. RESULTS: A total of 28 deans and 46 fellows responded. Fifteen medical schools had clinical teaching fellows and there appeared to be a total of 77 such posts in the UK. There was little uniformity in the activities undertaken within the posts. Deans who employed clinical teaching fellows were unanimously positive regarding the posts. Fellows were generally positive but expressed reservations relating to approval for postgraduate training, career development, deterioration in clinical skills, financial disincentives, credibility within one's own specialty, and provision of training and support. CONCLUSIONS: Clinical teaching fellow posts are generally enjoyed by fellows and valued by deans. Fellows carry out differing duties and their training in medical education is variable. The posts can be unstructured and may lack credibility to doctors outside medical education. Providing specific structured training in medical education, recognised at a national level, would help deal with these concerns.