Making sense of how physician preceptors interact with medical students: discourses of dialogue, good medical practice, and relationship trajectories

A meta-study analysing the discourses of discourse analysis in health professions education

INTRODUCTION

Discourse analysis has been used as an approach to conducting research in health professions education (HPE) for many years. However, because there is no one 'right' interpretation of or approach to it, quite what discourse analysis is, how it could or should be used, and how it can be appraised are unclear. This ambiguity risks undermining the trustworthiness and coherence of the methodology and any findings it produces.

METHOD

A meta-study review was conducted to explore the current state of discourse analysis in HPE, to guide researchers engaging using the methodology and to improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and 124 articles critically analysed.

RESULTS

Of 124 included articles, 64 were from medical education, 51 from nursing and 9 were mutli-disciplinary or from other HPE disciplines. Of 119 articles reporting some sort of data, 50 used documents/written text as the sole data source, while 27 were solely based on interview data. Foucault was the most commonly cited theorist (n = 47), particularly in medical education articles. The quality of articles varied: many did not provide a clear articulation what was meant by discourse, definitions and methodological choices were often misaligned, there was a lack of detail regarding data collection and analysis, and positionality statements and critiques were often underdeveloped or absent.

DISCUSSION

Seeking to address these many lacunae, the authors present a framework to facilitate rigorous discourse analysis research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from discourse analysis in HPE. Scholars are encouraged to reflect more deeply on the applications and practices of discourse analysis, with the ultimate aim of ensuring more breadth and depth when using discourse analysis for understanding and constructing meaning in our field.

Becoming a general practice supervisor: A longitudinal multi-case study exploring key supportive factors

INTRODUCTION

Supervision of trainees in the health care professions is recognised internationally as core to safe and effective patient care. A supervisor workforce in general practice (GP) is critical to the profession and to the communities where they work and can be demanding as general practitioners incorporate workplace-based education and support of their trainees into their daily consulting work. Little is known about how this is experienced by new supervisors; therefore, this research sought to understand factors that play a significant role in the first semester of becoming a supervisor.

METHODS

An exploratory multi-case study design was used; new general practice supervisors were the unit of analysis. Four data sources were captured longitudinally: semi-structured interviews at the beginning and end of the semester, audio diaries throughout and a mid-semester focus group. Template analysis was used, sensitised by a community of practice theoretical framework.

RESULTS

Seven new supervisors participated. Five interdependent key factors played a significant role in general practitioners becoming supervisors: (1) making meaning of the role, (2) reconciling multiple roles, (3) building a relationship with the trainee, (4) receiving support from the training practice and the training programme and (5) joining peer communities of new and experienced supervisors.

CONCLUSION

Becoming a general practice supervisor is situated in the context of a workplace delivering clinical services, a training programme and personal life circumstances. It can be challenging and rewarding. Insufficient support may result in unintended attrition. Learning in this role is facilitated by enabling the new supervisor to find meaning in the role; structured allocation of time to engage effectively; a positive trainee-supervisor relationship; administrative support by practices; information, advice and remuneration from the training programme; and interactions with new and experienced supervisor peers.

Midwives' experiences of professional learning when practicing collegial midwifery assistance during the active second stage of labour: data from the oneplus trial

BACKGROUND

Learning is a lifelong process and the workplace is an essential arena for professional learning. Workplace learning is particularly relevant for midwives as essential knowledge and skills are gained through clinical work. A clinical practice known as 'Collegial Midwifery Assistance' (CMA), which involves two midwives being present during the active second stage of labour, was found to reduce severe perineal trauma by 30% in the Oneplus trial. Research regarding learning associated with CMA, however, is lacking. The aim was to investigate learning experiences of primary and second midwives with varying levels of work experience when practicing CMA, and to further explore possible factors that influence their learning.

METHODS

The study uses an observational design to analyse data from the Oneplus trial. Descriptive statistics and proportions were calculated with 95% confidence intervals. Stratified univariable and multivariable logistic regression analysis were performed.

RESULTS

A total of 1430 births performed with CMA were included in the study. Less experienced primary midwives reported professional learning to a higher degree (< 2 years, 76%) than the more experienced (> 20 years, 22%). A similar but less pronounced pattern was seen for the second midwives. Duration of the intervention ≥ 15 min improved learning across groups, especially for the least experienced primary midwives. The colleague's level of experience was found to be of importance for primary midwives with less than five years' work experience, whereas for second midwives it was also important in their mid to late career. Reciprocal feedback had more impact on learning for the primary midwife than the second midwife.

CONCLUSIONS

The study provides evidence that CMA has the potential to contribute with professional learning both for primary and second midwives, for all levels of work experience. We found that factors such as the colleague's work experience, the duration of CMA and reciprocal feedback influenced learning, but the importance of these factors were different for the primary and second midwife and varied depending on the level of work experience. The findings may have implications for future implementation of CMA and can be used to guide the practice.

How workplace learning is put into practice: contrasting the medical and nursing contexts from the perspective of teaching and learning regimes

Health professions education places significant emphasis on learning in the clinical environment. While experiences of workplace learning have been extensively investigated, practices of workplace learning explored through field work have been less utilized. The theoretical framework of teaching and learning regimes acknowledges aspects of power and conflict in its consideration of what guides teachers and learners in their practice of workplace learning. This study aimed to explore practices of workplace learning in the two adjacent healthcare professions; medicine and nursing. We adopted an ethnographic qualitative design. Field observations and follow-up interviews were performed in three clinical departments and the data set comprised 12 full days of observations and 16 formal follow-up interviews. Thematic analysis was performed deductively according to the theoretical framework. Four teaching and learning regimes were found in the data. In the medical context, workplace learning was either practiced as reproduction of current practice or through stimulation of professional development. In the nursing context, workplace learning was either based on development of partnership between student and supervisor or on conditional membership in a professional community. The medical and nursing contexts demonstrated varying underpinnings and assumptions relating to teaching and learning. The respective practices of workplace learning in the medical and nursing context appear to hold substantial differences which might have implications for how we understand practices of workplace learning. We further conclude that the theoretical framework of teaching and learning regimes in this study proved useful in exploring workplace learning.

An exploratory university-based cross-sectional study of the prevalence and reporting of mistreatment and student-related factors among Thai medical students

BACKGROUND

Mistreatment is a behavior that reflects disrespect for the dignity of others. Mistreatment can be intentional or unintentional, and can interfere with the process of learning and perceived well-being. This study explored the prevalence and characteristics of mistreatment, mistreatment reporting, student-related factors, and consequences among medical students in Thai context.

METHODS

We first developed a Thai version of the Clinical Workplace Learning Negative Acts Questionnaire-Revised (NAQ-R) using a forward-back translation process with quality analysis. The design was a cross-sectional survey study, using the Thai Clinical Workplace Learning NAQ-R, Thai Maslach Burnout Inventory-Student Survey, Thai Patient Health Questionnaire (to assess depression risk), demographic information, mistreatment characteristics, mistreatment reports, related factors, and consequences. Descriptive and correlational analyses using multivariate analysis of variance were conducted.

RESULTS

In total, 681 medical students (52.4% female, 54.6% in the clinical years) completed the surveys (79.1% response rate). The reliability of the Thai Clinical Workplace Learning NAQ-R was high (Cronbach's alpha 0.922), with a high degree of agreement (83.9%). Most participants (n = 510, 74.5%) reported that they had experienced mistreatment. The most common type of mistreatment was workplace learning-related bullying (67.7%), and the most common source was attending staff or teachers (31.6%). People who mistreated preclinical medical students were most often senior students or peers (25.9%). People who mistreated clinical students were most commonly attending staff (57.5%). Only 56 students (8.2%) reported these instances of mistreatment to others. Students' academic year was significantly related to workplace learning-related bullying (r = 0.261, p < 0.001). Depression and burnout risk were significantly associated with person-related bullying (depression: r = 0.20, p < 0.001, burnout: r = 0.20, p = 0.012). Students who experienced person-related bullying were more often the subject of filed unprofessional behavior reports, concerning conflict or arguments with colleagues, being absent from class or work without reasonable cause, and mistreatment of others.

CONCLUSIONS

Mistreatment of medical students was evident in medical school and was related to the risk for depression and burnout, as well as the risk of unprofessional behavior.

TRIAL REGISTRATION

TCTR20230107006(07/01/2023).

Using audio-diaries for research and education: AMEE Guide No. 144

For this AMEE Guide, we explore the process and application of an evolved tool known as the audio diary. Diaries are a type of qualitative method that has long been advocated for in healthcare education practice and research. However, this tool has been typically underestimated as an approach to capturing how individuals' experiences change over time. In particular, this longitudinal method can nurture a stronger partnership between the researcher and participant, which can empower participants to share their reflections as they make sense of their identities and experiences. There is a wider issue concerning how to use and implement audio diaries in medical education research, this guide outlines a foundational process by which all levels of researchers can use to ensure the purpose, application and use of the audio diary tool is done with quality, rigour and ethics in mind. The processes presented are not a prescriptive approach to utilising audio diaries as a longitudinal method. This AMEE Guide serves as an opportunity for researchers and educators to consult this resource in making decisions to decide whether the audio diary tool is fit for their research and/or educational purpose and how audio diaries can be implemented in health profession education projects. This guide discusses and addresses some of the ethical, operational and contextual considerations that can arise from using audio diaries as a tool for longitudinal data collection, critical reflection, or understanding professionalism.

Best Practices for Integrating Medical Students Into Telehealth Visits

Telehealth has become an increasingly important part of health care delivery, with a dramatic rise in telehealth visits during the COVID-19 pandemic. Telehealth visits will continue to be a part of care delivery after the pandemic subsides, and it is important that medical students receive training in telehealth skills to meet emerging telehealth competencies. This paper describes strategies for successfully integrating medical students into telehealth visits in the ambulatory setting based on existing literature and the extensive experience of the authors teaching and learning in the telehealth environment.

A Curriculum for Enhancing Physician Teaching Skills: The Value of Physician-Educator Partnerships

Developing as a physician requires an enormous amount of complex training, and quality of instruction greatly affects training outcomes. But while physicians are expected to teach trainees within the clinic, they often do not receive formal training in effective instructional practices. Providing faculty development programs is one way that institutions can help physicians develop teaching skills, but these programs often are developed without the input of educational specialists and not based in educational theory. In this methodology paper, we describe a 5-module curriculum that was developed in a cross-disciplinary collaboration between instructional designers and physician faculty. By merging educational and medical expertise and using adult learning theory with the Charlotte-Danielson educational framework, an essentials for clinical teaching educational endorsement program (ECTEEP) was created as a feature of the institutional curriculum within a large, urban teaching hospital. Here we describe how the program was developed through a physician-educator partnership, outline the program's key content, and highlight essential aspects of successful implementation. The ECTEEP incorporates active learning approaches within an abbreviated format, distilling 5 critical aspects of effective teaching that are relevant to the clinical environment: cultural humility and safe learning environments, instruction practices for engaging learners, instruction and assessment strategies, receiving and giving feedback, and mentorship and coaching. A central feature of the program is that facilitators actively model the teaching behaviors they are conveying, which underscores the critical importance of facilitator preparation and skill. Our curriculum is offered here as a basic template for institutions that may want to establish a program for enhancing physician teaching skill.

How to … do longitudinal qualitative research

In health professions education, we are often interested in researching change over time, for example the development of professional identity or the adoption of new practices. Taking a longitudinal qualitative approach to such research can provide valuable insights. In this article, we present some longitudinal qualitative methods to support researchers interested in getting started with this type of research. We discuss what longitudinal qualitative approaches offer, consider the challenges and suggest how to go about it. We also highlight some specific ethical considerations that may arise in longitudinal studies.

Learning to interact and interacting to learn: a substantive theory of clinical workplace learning for diverse cohorts

Social interactions are integral to clinical workplace functioning and are recognised to play an important role in clinical workplace learning. How, why and to what end students, in the context of today's culturally and linguistically diverse cohorts, interact with members of clinical workplace communities during clinical workplace learning is not well understood. The aim of this research was to generate a theoretical understanding of students' interactive processes in clinical workplace learning that accounted for high levels of cultural/linguistic diversity. In accordance with constructivist grounded theory methods, data collection and analysis were premised on theoretical sampling and constant comparative analysis, and undertaken from an informed and reflexive stance. This involved iterations of survey, interview and diary data from two diverse cohorts of final year veterinary students who had undergone 11 months of clinical workplace learning. Clinical preceptors were also interviewed. As an aid to theory building, testing and refinement, and in order to test the theory's relevance, usefulness and transferability beyond veterinary clinical education, critical feedback was sought from medical and allied health educators. Our substantive level theory demonstrates that upon entering the clinical workplace community, students learn how to 'harness dialogue' in order to effectively coordinate three, inter-related interactive processes: (i) functioning in the workplace, (ii) impression management and (iii) learning-in-the-moment. We found both positive and negative consequences ensued, depending on how students harnessed dialogue. The theory responds to a perceived need in international student education to move away from a deficit discourse by developing educational theory which focuses on the nature of participation, rather than the nature of the student.

Community Preceptors' Motivations and Views about Their Relationships with Medical Students During a Longitudinal Family Medicine Experience: A Qualitative Case Study

Phenomenon: Although current evidence emphasizes various benefits of community-oriented programs, little is still known about the nature of the relationships that students and family physicians develop in this educational setting. Our aim in this study was twofold: to identify family physicians' motivations to enroll as preceptors in a longitudinal undergraduate family medicine program and to explore the nature of the student-preceptor relationships built during the course. Approach: This was a qualitative exploratory case study. The case was the first edition of a longitudinal family medicine experience (LFME), a course that makes up part of the novel Medicinae Doctor et Chirurgiae Magister curriculum in place in a Canadian medical school since August 2013. All 173 family physician community preceptors of the academic year 2013-2014 were considered key informants in the investigation. Forty-three preceptors finally participated in one of six focus groups conducted in the spring of 2014. Several organizational documents relative to the LFME course were also gathered. Inductive semantic thematic analysis was performed on verbatim interview transcripts. Documents helped contextualize the major themes emerging from the focus groups discussions. Findings: Enjoying teaching, promoting family medicine, and improving medical education where salient motivations for family physicians to become LFME preceptors. The findings also pointed out the complexity of the student-preceptor exchanges that unfolded over the academic year, and the ambiguous and changing nature of the role that LFME preceptors adopted in their relationships with students: from simply being facilitators of students' clinical observership to behaving as their mentors. Insights: Family physicians were highly motivated to become LFME preceptors of 1st-year medical students. Whereas they consistently valued the relationships built during the academic year with the students assigned to them, they also considered that exchanges did not always happen without difficulties, and gauged the roles they played as complex, ambiguous, and necessarily evolving over time.

Am I Being Understood? Veterinary Students' Perceptions of the Relationship between Their Language Background, Communication Ability, and Clinical Learning

During clinical workplace learning, effective communication between veterinary students and clinical staff is of paramount importance to facilitating learning, assessment, and patient care. Although studies in health sciences education have indicated that students may experience communication difficulties as a result of linguistic, cultural, and other factors and that these difficulties can affect clinical learning and academic outcomes, this has not yet been explored in veterinary clinical educational contexts. In this study, the authors sought to identify whether final-year veterinary students perceived that their communication ability influenced their clinical learning and, if so, whether language background was of significance. Seventy-one students from a final-year cohort at an Australian veterinary school completed a student perception survey at the end of their clinical training. Exploratory factor analysis was used to investigate the extent to which learners perceived that their communication ability influenced their clinical learning. Two factors explained 72.3% of total variance. Factor 1 related to communication ability as a source of concern; Factor 2 related to comprehending and contributing to clinical conversations. Communication ability as a source of concern differed significantly ( p < .001) between students who did and did not have an English-speaking background, but there was no significant difference between these two student groups for Factor 2. Although language background was associated with self-perceived communication ability, evidence also emerged that students may experience communication challenges during clinical learning, irrespective of their language background.

It's all about relationships : A qualitative study of family physicians' teaching experiences in rural longitudinal clerkships

INTRODUCTION

The relationship between preceptor and trainee is becoming recognized as a critical component of teaching, in particular in the negotiation of feedback and in the formation of professional identity. This paper elaborates on the nature of the relationships between preceptor and student that evolve in the context of rural longitudinal integrated clerkships (LICs).

METHODS

We drew on constructivist grounded theory for the research approach. We interviewed nine LIC family practice preceptors from three sites at one educational institution. We adapted the interview framework based on early findings. We analyzed the data through a constant comparative process. We then drew on concepts of relationship-based learning as sensitizing concepts in a secondary analysis.

RESULTS

We constructed three themes from the data. First, preceptors developed trusting professional and personal relationships with students over time. These relationships expanded to include friendship, advocacy, and ongoing contact beyond the clerkship year. Second, preceptors' approach to teaching was anchored in the relationship with an understanding of the individual student. Third, preceptors set learning goals collaboratively with their students, based not only on program objectives, but also with the student as a future physician in mind.

DISCUSSION

Our findings suggest that rural family medicine preceptors developed engaged and trusting relationships with their students over time. These relationships imbued all activities of teaching and learning with an individual and personal focus. This orientation may be a key factor in supporting the learning outcomes demonstrated for students studying in rural LICs.

Am I ready for it? Students' perceptions of meaningful feedback on entrustable professional activities

BACKGROUND

Receiving feedback while in the clinical workplace is probably the most frequently voiced desire of students. In clinical learning environments, providing and seeking performance-relevant information is often difficult for both supervisors and students. The use of entrustable professional activities (EPAs) can help to improve student assessment within competency-based education. This study aimed to illustrate what students' perceptions are of meaningful feedback viewed as conducive in preparing for performing EPA unsupervised.

METHODS

In a qualitative multicentre study we explored students' perceptions on meaningful feedback related to EPAs in the clinical workplace. Focus groups were conducted in three different healthcare institutes. Based on concepts from the literature, the transcripts were coded, iteratively reduced and displayed.

RESULTS

Participants' preferences regarding meaningful feedback on EPAs were quite similar, irrespective of their institution or type of clerkship. Participants explicitly mentioned that feedback on EPAs could come from a variety of sources. Feedback must come from a credible, trustworthy supervisor who knows the student well, be delivered in a safe environment and stress both strengths and points for improvement. The feedback should be provided immediately after the observed activity and include instructions for follow-up. Students would appreciate feedback that refers to their ability to act unsupervised.

CONCLUSION

There is abundant literature on how feedback should be provided, and what factors influence how feedback is sought by students. This study showed that students who are training to perform an EPA unsupervised have clear ideas about how, when and from whom feedback should be delivered.

Ad hoc supervision of general practice registrars as a 'community of practice': analysis, interpretation and re-presentation

General practice registrars in Australia undertake most of their vocational training in accredited general practices. They typically see patients alone from the start of their community-based training and are expected to seek timely ad hoc support from their supervisor. Such ad hoc encounters are a mechanism for ensuring patient safety, but also provide an opportunity for learning and teaching. Wenger's (Communities of practice: learning, meaning, and identity. Cambridge University Press, New York, 1998) social theory of learning ('communities of practice') guided a secondary analysis of audio-recordings of ad hoc encounters. Data from one encounter is re-presented as an extended sequence to maintain congruence with the theoretical perspective and enhance vicariousness. An interpretive commentary communicates key features of Wenger's theory and highlights the researchers' interpretations. We argue that one encounter can reveal universal understandings of clinical supervision and that the process of naturalistic generalisation allows readers to transfer others' experiences to their own contexts. The paper raises significant analytic, interpretive, and representational issues. We highlight that report writing is an important, but infrequently discussed, part of research design. We discuss the challenges of supporting the learning and teaching that arises from adopting a socio-cultural lens and argue that such a perspective importantly captures the complex range of issues that work-based practitioners have to grapple with. This offers a challenge to how we research and seek to influence work-based learning and teaching in health care settings.

Experience, trajectories, and reifications: an emerging framework of practice-based learning in healthcare workplaces

Learning by working is omnipresent in healthcare education. It enables people to learn how to perform, think, and interact in ways that work for their specific context. In this paper, I review my approach to studying this process. It centers on the question why healthcare professionals do what they do and how their actions and learning are intertwined. The aim of this paper is to illustrate what I have learned from the research I have been involved in, in such a way that it enables other researchers, educators, and clinicians to understand and study practice-based learning in healthcare workplaces. Therefore, I build on a programmatic line of research to present a framework of practice-based learning consisting of three inextricably linked levels of analysis. The first level focuses on how situations lead to personal experiences, the second level looks at strings of experiences that lead to multiple trajectories, and the third level deals with reifications arising from recurrent activities. This framework, and its interrelations and inherent tensions, helps to understand why healthcare workplaces can be both a powerful learning environment and a frustratingly hard place to change.

The power of questions: a discourse analysis about doctor-student interaction

CONTEXT

During clerkships, teaching and learning in day-to-day activities occur in many moments of interaction among doctors, patients, peers and other co-workers. How people talk with one another influences their identity, their position and what they are allowed to do. This paper focuses on the opportunities and challenges of such moments of interaction between doctors and students during a clerkship characterised by short supervisory relationships.

METHODS

This study was conducted in a 10-week internal medicine clerkship. Nine students and 10 doctors who worked with these nine students participated by regularly describing moments of interaction, using dictaphones. We performed critical discourse analysis of material sourced from a total of 184 audio diary entries and seven student debriefing interviews to reveal how participants discursively shaped the way they could think, speak and conduct themselves.

RESULTS

The ways in which doctors and students posed and answered questions represented a recurrent and influential feature in the diaries. This Question and Answer dynamic revealed six discourses of Basic Learning Need, Care and Attention, Power Game, Exchange of Currency, Distance, and Equality and Reciprocity. These discourses and the interplay among them revealed both students' and doctors' frameworks of needs and expectations in a culturally defined power structure. The interplay among the discourses reflected the ways in which doctor-student interactions afforded meaningful contributions to their medical or educational practice such as in the exchange of authentic professional or personal experience.

CONCLUSIONS

By purposefully bringing power structures to the surface, we have addressed the complexity of learning and teaching as it occurs in day-to-day moments of interaction in a clerkship with little continuity in supervision. Both doctors and students should be supported to reflect critically on how they contribute to supervisory relationships with reference to, for example, the ways in which they ask or answer questions.