Workforce, learners, competencies, and the learning environment: Research in Medical Education 2014 and the way forward

Stakeholder Groups' Unique Perspectives About the Attending Physician Preceptor Role: A Qualitative Study

BACKGROUND

Attending physician preceptors are accountable to many stakeholder groups, yet stakeholders' views about what the preceptor role entails have not been sufficiently considered.

OBJECTIVE

To explore stakeholder groups' unique perspectives of the preceptor role.

DESIGN

Qualitative study with a constructivist orientation.

PARTICIPANTS

Semi-structured interviews were conducted with 73 participants from two university teaching hospitals between October 2012 and March 2014. Participants included representatives from seven stakeholder groups: patients and their families, allied healthcare providers, bedside nurses, nurse managers, medical students, internal medicine residents, and preceptors.

APPROACH

An inductive thematic analysis was conducted where researchers coded transcripts, abstracted codes into themes, and then mapped themes onto six focus areas: role dimensions, role performance, stressors and rewards, mastery, fulfillment, and impact on others. Two authors then identified "recurrent themes" (emerging in two or more focus areas) and compared them across groups to identify "unique themes" (emerging from a maximum of two stakeholder groups). "Unique thematic emphases" (unique themes that would not have emerged if a stakeholder group was not interviewed) are described.

KEY RESULTS

Patients and their families emphasized preceptors' ultimate authority. Allied healthcare providers described preceptors as engaged collaborators involved in discharge planning and requiring a sense of humor. Bedside nurses highlighted the need for role standardization. Nurse managers stressed preceptors' need for humanism. Medical students highlighted preceptors' emotional labor and their influence on learners' emotional well-being. Residents emphasized preceptors' responsibilities to multiple stakeholders. Preceptors described lifelong learning and exercising control over one's environment.

CONCLUSIONS

Various stakeholder groups hold unique and nuanced views of the attending physician preceptor role. These views could broaden formal role guidance for medical education and patient care. This study generated real-world, practical examples of what stakeholders feel are important preceptor skills. These skills should be practiced, taught, and role modeled in this clinical setting.

How evidence from observing attending physicians links to a competency-based framework

CONTEXT

Competency-based medical education frameworks are often founded on a combination of existing research, educational principles and expert consensus. Our objective was to examine how components of the attending physician role, as determined by observing preceptors during their real-world work, link to the CanMEDS Physician Competency Framework.

METHODS

This is a sub-study of a broader study exploring the role of the attending physician by observing these doctors during their working day. The parent study revealed three overarching elements of the role that emerged from 14 themes and 123 sub-themes: (i) Competence, defined as the execution of traditional physician competencies; (ii) Context, defined as the environment in which the role is carried out, and (iii) Conduct, defined as the manner of acting, or behaviours and attitudes in the role that helped to negotiate the complex environment. In this sub-study, each sub-theme, or 'role-related component', was mapped to the competencies described in the CanMEDS 2005 and 2015 frameworks.

RESULTS

Many role-related components from the Competence element were represented in the 2015 CanMEDS framework. No role-related components from the Context element were represented. Some role-related components from the Conduct element were represented. These Conduct role-related components were better represented in the 2015 CanMEDS framework than in the 2005 framework.

CONCLUSIONS

This study shows how the real-world work of attending physicians links to the CanMEDS framework and provides empirical data identifying disconnects between espoused and observed behaviours. There is a conceptual gap where the contextual influences of physicians' work and the competencies required to adjust to these influences are missing from the framework. These concepts should be incorporated into learning both broadly, such as through an emphasis on context within curriculum development for the workplace (e.g. entrustable professional activities), and explicitly, through the introduction of novel competencies (e.g. the Conduct role-related components described in this study).

Assessing the Learning Environment for Medical Students: An Evaluation of a Novel Survey Instrument in Four Medical Schools

OBJECTIVE

A practical, reliable, and valid instrument is needed to measure the impact of the learning environment on medical students' well-being and educational experience and to meet medical school accreditation requirements.

METHODS

From 2012 to 2015, medical students were surveyed at the end of their first, second, and third year of studies at four medical schools. The survey assessed students' perceptions of the following nine dimensions of the school culture: vitality, self-efficacy, institutional support, relationships/inclusion, values alignment, ethical/moral distress, work-life integration, gender equity, and ethnic minority equity. The internal reliability of each of the nine dimensions was measured. Construct validity was evaluated by assessing relationships predicted by our conceptual model and prior research. Assessment was made of whether the measurements were sensitive to differences over time and across institutions.

RESULTS

Six hundred and eighty-six students completed the survey (49 % women; 9 % underrepresented minorities), with a response rate of 89 % (range over the student cohorts 72-100 %). Internal consistency of each dimension was high (Cronbach's α 0.71-0.86). The instrument was able to detect significant differences in the learning environment across institutions and over time. Construct validity was supported by demonstrating several relationships predicted by our conceptual model.

CONCLUSIONS

The C-Change Medical Student Survey is a practical, reliable, and valid instrument for assessing the learning environment of medical students. Because it is sensitive to changes over time and differences across institution, results could potentially be used to facilitate and monitor improvements in the learning environment of medical students.

A model of influences on the clinical learning environment: the case for change at one U.S. medical school

BACKGROUND

The learning environment within a school of medicine influences medical students' values and their professional development. Despite national requirements to monitor the learning environment, mistreatment of medical students persists.

METHODS

We designed a program called WE SMILE: We can Eradicate Student Mistreatment In the Learning Environment with a vision to enhance trainee and faculty awareness and ultimately eliminate medical student mistreatment. We provide a description of our program and early outcomes.

RESULTS

The program has enhanced student awareness of what constitutes mistreatment and how to report it. Faculty members are also aware of the formal processes and procedures for review of such incidents. Our proposed model of influences on the learning environment and the clinical workforce informs the quality of trainee education and safety of patient care. Institutional leadership and culture play a prominent role in this model. Our integrated institutional response to learning environment concerns is offered as a strategy to improve policy awareness, reporting and management of student mistreatment concerns.

CONCLUSIONS

Our WE SMILE program was developed to enhance education and awareness of what constitutes mistreatment and to provide multiple pathways for student reporting, with clear responsibilities for review, adjudication and enforcement. The program is demonstrating several signs of early success and is offered as a strategy for other schools to adopt or adapt. We have recognized a delicate balance between preserving student anonymity and informing them of specific actions taken. Providing students and other stakeholders with clear evidence of institutional response and accountability remains a key challenge. Multiple methods of reporting have been advantageous in eliciting information on learning environment infringements. These routes and types of reporting have enhanced our understanding of student perceptions and the specific contexts in which mistreatment occurs, allowing for targeted interventions. A common platform across the healthcare professions to report and review concerns has afforded us opportunities to deal with interprofessional issues in a respectful and trustworthy manner. We offer a model of learning environment influences with leadership and institutional culture at the helm, as a way to frame a comprehensive perspective on this challenging and complex concern.

Scholarly Conversations in Medical Education

This supplement includes the eight research papers accepted by the 2016 Research in Medical Education Program Planning Committee. In this Commentary, the authors use "conversations in medical education" as a guiding metaphor to explore what these papers contribute to the current scholarly discourse in medical education. They organize their discussion around two domains: the topic of study and the methodological approach. The authors map the eight research papers to six "hot topics" in medical education: (1) curriculum reform, (2) duty hours restriction, (3) learner well-being, (4) innovations in teaching and assessment, (5) self-regulated learning, and (6) learning environment, and to three purposes commonly served by medical education research: (1) description, (2) justification, and (3) clarification. They discuss the range of methods employed in the papers. The authors end by encouraging educators to engage in these ongoing scholarly conversations.