Coaching Versus Competency to Facilitate Professional Identity Formation

Tips for developing a coaching program in medical education

This article provides structure to developing, implementing, and evaluating a successful coaching program that effectively meets the needs of learners. We highlight the benefits of coaching in medical education and recognize that many educators desiring to build coaching programs seek resources to guide this process. We align 12 tips with Kern's Six Steps for Curriculum Development and integrate theoretical frameworks from the literature to inform the process. Our tips include defining the reasons a coaching program is needed, learning from existing programs and prior literature, conducting a needs assessment of key stakeholders, identifying and obtaining resources, developing program goals, objectives, and approach, identifying coaching tools, recruiting and training coaches, orienting learners, and evaluating program outcomes for continuous program improvement. These tips can serve as a framework for initial program development as well as iterative program improvement.

Navigating the paradox: Exploring resident experiences of vulnerability

INTRODUCTION

Learning and growth in postgraduate medical education (PGME) often require vulnerability, defined as a state of openness to uncertainty, risk, and emotional exposure. However, vulnerability can threaten a resident's credibility and professional identity. Despite this tension, studies examining vulnerability in PGME are limited. As such, this study aims to explore residents' experiences of vulnerability, including the factors that influence vulnerability in PGME.

METHODS

Using a constructivist grounded theory approach, individual semi-structured interviews were conducted with 15 residents from 10 different specialities. Interview transcripts were coded and analysed iteratively. Themes were identified and relationships among themes were examined to develop a theory describing vulnerability in PGME.

RESULTS

Residents characterised vulnerability as a paradox represented by two overarching themes. 'Experiencing the tensions of vulnerability' explores the polarities between being a fallible, authentic learner and an infallible, competent professional. 'Navigating the vulnerability paradox' outlines the factors influencing the experience of vulnerability and its associated outcomes at the intrapersonal, interpersonal, and systems levels. Residents described needing to have the bandwidth to face the risks and emotional labour of vulnerability. Opportunities to build connections with social agents, including clinical teachers and peers, facilitated vulnerability. The sociocultural context shaped both the experience and outcomes of vulnerability as residents faced the symbolic mask of professionalism.

CONCLUSION

Residents experience vulnerability as a paradox shaped by intrapersonal, interpersonal, and systems level factors. These findings capture the nuance and complexity of vulnerability in PGME and offer insight into creating supportive learning environments that leverage the benefits of vulnerability while acknowledging its risks. There is a need to translate this understanding into systems-based change to create supportive PGME environments, which value and celebrate vulnerability.

How to be a good clerk on the clinical teaching team: a scoping review

Background

As medical institutions shift towards Competency Based Education, more effort is being directed towards understanding how healthcare teams' function competently. While many have studied the competencies required to be a successful clerk, few have examined this question within the context of team function and integration. Our primary objective is to identify how medical clerks successfully integrate and contribute to clinical teaching teams.

Methods

We performed a scoping review of the literature using the Ovid MEDLINE database. Data was extracted and thematically analysed in accordance with Arksey and O'Malley's (2005) approach to descriptive analysis.

Results

Out of 1368 papers returned by our search, 12 studies were included in this review. Seven main themes were identified amongst the included studies: (1) Communication (2) Taking Responsibility and Appropriate Autonomy (3) Humility and Knowing When to Ask for Help (4) Identity as a Team Member, (5) Self-Efficacy (6) Rapport and Relationship Building (7) Patient Advocacy.

Conclusion

Analysis of these themes revealed four major findings: (i) The importance of documentation skills and communication towards team contribution (ii) The important connection between professional identity development and self-efficacy (iii) The impact of rapport on the reciprocity of trust between team members (iv) The role of clerks as patient advocates is poorly understood. This review also illustrates that there is a relative dearth of literature in this area. Future studies are needed to develop clear guidance on how clerks should perform these competencies in the context of team function and integration.

A scoping review and theory-informed conceptual model of professional identity formation in medical education

INTRODUCTION

Professional identity formation (PIF) is a central tenet of effective medical education. However, efforts to support, assess and study PIF are hindered by unclear definitions and conceptualisations of what it means to 'think, act, and feel like a physician'. Gaps in understanding PIF, and by extension, its support mechanisms, can predispose individuals towards disengaged or unprofessional conduct and institutions towards short-sighted or reactionary responses to systemic issues.

METHODS

A Systematic Evidence-Based Approach-guided systematic scoping review of PIF theories was conducted related to medical students, trainees and practising doctors, published between 1 January 2000 and 31 December 2021 in PubMed, Embase, ERIC and Scopus databases.

RESULTS

A total of 2441 abstracts were reviewed, 607 full-text articles evaluated and 204 articles included. The domains identified were understanding PIF through the lens of pivotal theories and characterising PIF by delineating the underlying factors that influence it and processes that define it.

CONCLUSIONS

Based on regnant theories and frameworks related to self-concepts of identity and personhood, the relationships between key PIF influences, processes and outcomes were examined. A theory-backed integrated conceptual model was proposed to delineate the interconnected relationships among these, aiming to untangle some of the complexities inherent to PIF, to shed light on existing practices and to identify shortcomings in our understanding so as to develop mechanisms in support of its multifaceted, interlinked components.

Navigating Confidentiality Dilemmas in Student Support: An Institutional Ethnography Informed Study

Introduction

School-level student support programmes provide students with pastoral care and support for academic, wellbeing and other issues often via a personal tutor (PT). PT work is a balancing act between respecting the confidential information divulged by students and doing what is expected in terms of accountability and duty of care. We aimed to explore how tutors manage this tension, with the aim of advancing understanding of student support programmes.

Methods

This qualitative study was informed by an Institutional Ethnography approach. We conducted 11 semi-structured interviews with PTs from one medical school in Singapore. We considered how they worked in relation to relevant national and institutional-level policy documents and reporting guidelines. Data collection and analysis were iterative.

Results

We crafted two composite accounts to illustrate the dilemmas faced by PTs. The first depicts a PT who supports student confidentiality in the same way as doctor-patient confidentiality. The second account is a PT who adopted a more mentoring approach. Both tutors faced confidentiality challenges, using different strategies to "work around" and balance tensions between accountability and maintaining trust. PTs were torn between school and student expectations.

Discussion

Fostering trust in the tutor-student relationship is a priority for tutors but tensions between confidentiality, accountability and governance sometimes make it difficult for tutors to reconcile with doing what they think is best for the student. A more nuanced understanding of the concept of confidentiality may help support PTs and ultimately students.

Beware False Growth Mindset: Building Growth Mindset in Medical Education Is Essential but Complicated

ABSTRACT

Mindset theory aims to explain how learners' beliefs about intelligence and learning affect how they perceive effort, react to failure, and respond to feedback in challenging learning contexts. Mindset theory distinguishes between growth mindset (the belief that human capacities can be developed over time) and fixed mindset (the belief that human capacities are inherent and unchangeable). Efforts to develop growth mindset in learners have shown a wide range of benefits, including positive effects on students' resilience, commitment to lifelong learning, and persistence in a field of study, with notable impacts on learners who are struggling, learners from minoritized groups, and women in scientific fields. In recent years, mindset theory interventions have caught the interest of medical educators hoping to engage learners as partners in their own learning and progression to competence. Educators hoping to apply this theory to educational programs and learner-teacher interactions in ways that promote growth mindsets would benefit from awareness of the concept of false growth mindset , a term coined by Carol Dweck to refer to common pitfalls in the theory's application. In this article, the authors highlight important findings from mindset interventions in medical education, identify common pitfalls of false growth mindset in the context of medical learners, and offer suggestions for how educators and institutions can better instigate changes to promote growth mindsets within medical education.

Competency in medical training: current concepts, assessment modalities, and practical challenges

In the past two decades, competency-based medical education (CBME) has rapidly become the cornerstone of medical training and accreditation programmes worldwide. It has increasingly replaced traditional time-based educational approaches which were often rigid, fragmented, and overly emphasized clinical content knowledge over practical skillsets and attitudes. CBME adoption was in the hope of better preparing medical graduates for the demands and responsibilities of real-world clinical practice. For all the supposed merits of CBME, there hitherto remains difficulties in arriving at comprehensive and practical 'competency' definitions, and actual challenges with implementation of clinical competency assessment modalities pertaining to construct validity, reliability, and applicability with the use and interpretation of evaluation metrics. Therefore, in this article, we describe the various conceptualizations of 'competency' in medical education literature and attempt to refine its usage in practice to meet the evolving needs and expectations of healthcare stakeholders, as well as incorporate emerging concepts in the medical education discourse. We herein propose that clinical 'competencies' should be defined as multi-domain clinical expertise, comprising medical knowledge, skills, attitudes and metacognitive capabilities that reflects the prevailing needs of healthcare stakeholders, and is inferred from performance evaluations of medical trainees. In order to attain 'competence', there must then be a process of integrating multi-domain competencies into meaningful professional identity formation that is commensurate with the context and stage of medical training. In addition, we review the current competency assessment modalities, including common pitfalls with their usage, and sought to provide practical strategies to mitigate the identified challenges.

Empowerment of Learners through Curriculum Co-Creation: Practical Implications of a Radical Educational Theory

Framing the Issue: Medical education programs in the U.S. rely on the aphorism that faculty own the curriculum; that is, the specialized knowledge, skills, and attitudes of a physician are the province of the faculty to be delivered to tuition-paying students. From this view, the learner's role is one of passivity and deference. A contrasting approach, termed curriculum co-creation, frames education as a bi-lateral partnership. Co-creation results from learners, in collaboration with instructors, taking an active role in creating the goals and processes of an educational program. Such a partnership requires substantial revision of the expectations for both learners and instructors. In this Observations article, the idea of co-creation is applied to medical education and an aspirational vision for the role and value of faculty-student co-creation is advocated. Description and Explication: Co-creation partnerships of faculty and students occur in many forms, varying in degree of departure from traditional educational practice. Co-creation principles and partnerships can be deployed for almost all aspects of training including selection and organization of content, effective methods of instruction, and assessment of student learning. The outcomes of co-creation occur at three levels. The most specific outcome of co-creation is characterized by increased student engagement and enhanced learning. Broader outcomes include improved efficacy and value in the educational program and institution while, at the farthest-reaching level, a co-creative process can modify the medical profession itself. Although some specific instructional techniques to promote student involvement and input have historically been deployed in medical education, there is little evidence that students have ever been permitted to share in ownership. Implications for Medical Education: When fully embraced, curricular co-creation will be recognizable through improved student engagement and learning along with a revised understanding of how faculty-student relationships can foment reform in medical education and the culture of the profession. Further scholarship and research will be indispensable to examine how co-creative partnerships can flatten hierarchies within medical education and inspire the medical profession to be more inclusive and effective. Following the model of co-creation is expected to inspire learners by empowering them to participate fully as co-owners of their own education and prepare them to lead medical education in a different direction for the future.

Coaching in Competence by Design: A New Model of Coaching in the Moment and Coaching Over Time to Support Large Scale Implementation

Coaching is an increasingly popular means to provide individualized, learner-centered, developmental guidance to trainees in competency based medical education (CBME) curricula. Aligned with CBME's core components, coaching can assist in leveraging the full potential of this educational approach. With its focus on growth and improvement, coaching helps trainees develop clinical acumen and self-regulated learning skills. Developing a shared mental model for coaching in the medical education context is crucial to facilitate integration and subsequent evaluation of success. This paper describes the Royal College of Physicians and Surgeons of Canada's coaching model, one that is theory based, evidence informed, principle driven and iteratively and developed by a multidisciplinary team. The coaching model was specifically designed, fit for purpose to the postgraduate medical education (PGME) context and implemented as part of Competence by Design (CBD), a new competency based PGME program. This coaching model differentiates two coaching roles, which reflect different contexts in which postgraduate trainees learn and develop skills. Both roles are supported by the RX-OCR process: developing Relationship/Rapport, setting eXpectations, Observing, a Coaching conversation, and Recording/Reflecting. The CBD Coaching Model and its associated RX-OCR faculty development tool support the implementation of coaching in CBME. Coaching in the moment and coaching over time offer important mechanisms by which CBD brings value to trainees. For sustained change to occur and for learners and coaches to experience the model's intended benefits, ongoing professional development efforts are needed. Early post implementation reflections and lessons learned are provided.

Supportive learning environments, impression management and 'strategic imposterism': A word of caution

Learning environments are critical to individual growth and expression. While high stakes environments can drive self‐doubt and imposterism, the authors warn that overly comfortable environments may encourage ‘strategic imposterism.’

Contradictions and Opportunities: Reconciling Professional Identity Formation and Competency-Based Medical Education

The widespread adoption of Competency-Based Medical Education (CBME) has resulted in a more explicit focus on learners' abilities to effectively demonstrate achievement of the competencies required for safe and unsupervised practice. While CBME implementation has yielded many benefits, by focusing explicitly on what learners are doing, curricula may be unintentionally overlooking who learners are becoming (i.e., the formation of their professional identities). Integrating professional identity formation (PIF) into curricula has the potential to positively influence professionalism, well-being, and inclusivity; however, issues related to the definition, assessment, and operationalization of PIF have made it difficult to embed this curricular imperative into CBME. This paper aims to outline a path towards the reconciliation of PIF and CBME to better support the development of physicians that are best suited to meet the needs of society. To begin to reconcile CBME and PIF, this paper defines three contradictions that must and can be resolved, namely: (1) CBME attends to behavioral outcomes whereas PIF attends to developmental processes; (2) CBME emphasizes standardization whereas PIF emphasizes individualization; (3) CBME organizes assessment around observed competence whereas the assessment of PIF is inherently more holistic. Subsequently, the authors identify curricular opportunities to address these contradictions, such as incorporating process-based outcomes into curricula, recognizing the individualized and contextualized nature of competence, and incorporating guided self-assessment into coaching and mentorship programs. In addition, the authors highlight future research directions related to each contradiction with the goal of reconciling 'doing' and 'being' in medical education.

Professional identity struggle and ideology: A qualitative study of residents' experiences

INTRODUCTION

To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency.

METHODS

We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings.

RESULTS

We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals.

CONCLUSION

This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Striving to thrive or striving to survive: Professional identity constructions of medical trainees in clinical assessment activities

CONTEXT

Assessment plays a key role in competence development and the shaping of future professionals. Despite its presumed positive impacts on learning, unintended consequences of assessment have drawn increasing attention in the literature. Considering professional identities and how these can be dynamically constructed through social interactions, as in assessment contexts, our study sought to understand how assessment influences the construction of professional identities in medical trainees.

METHODS

Within social constructionism, we adopted a discursive, narrative approach to investigate the different positions trainees narrate for themselves and their assessors in clinical assessment contexts and the impact of these positions on their constructed identities. We purposively recruited 28 medical trainees (23 students and five postgraduate trainees), who took part in entry, follow-up and exit interviews of this study and submitted longitudinal audio/written diaries across nine-months of their training programs. Thematic framework and positioning analyses (focusing on how characters are linguistically positioned in narratives) were applied using an interdisciplinary teamwork approach.

RESULTS

We identified two key narrative plotlines, striving to thrive and striving to survive, across trainees' assessment narratives from 60 interviews and 133 diaries. Elements of growth, development, and improvement were identified as trainees narrated striving to thrive in assessment. Neglect, oppression and perfunctory narratives were elaborated as trainees narrated striving to survive from assessment. Nine main character tropes adopted by trainees with six key assessor character tropes were identified. Bringing these together we present our analysis of two exemplary narratives with elaboration of their wider social implications.

CONCLUSION

Adopting a discursive approach enabled us to better understand not only what identities are constructed by trainees in assessment contexts but also how they are constructed in relation to broader medical education discourses. The findings are informative for educators to reflect on, rectify and reconstruct assessment practices for better facilitating trainee identity construction.

"It's All About the Trust And Building A Foundation:" Evaluation of a Longitudinal Medical Student Coaching Program

Coaching is increasingly implemented in medical education to support learners' growth, learning, and wellbeing. Data demonstrating the impact of longitudinal coaching programs are needed.

We developed and evaluated a comprehensive longitudinal medical student coaching program designed to achieve three aims for students: fostering personal and professional development, advancing physician skills with a growth mindset, and promoting student wellbeing and belonging within an inclusive learning community. We also sought to advance coaches' development as faculty through satisfying education roles with structured training. Students meet with coaches weekly for the first 17 months of medical school for patient care and health systems skills learning, and at least twice yearly throughout the remainder of medical school for individual progress and planning meetings and small-group discussions about professional identity. Using the developmental evaluation framework, we iteratively evaluated the program over the first five years of implementation with multiple quantitative and qualitative measures of students' and coaches' experiences related to the three aims.

The University of California, San Francisco, School of Medicine, developed a longitudinal coaching program in 2016 for medical students alongside reform of the four-year curriculum. The coaching program addressed unmet student needs for a longitudinal, non-evaluative relationship with a coach to support their development, shape their approach to learning, and promote belonging and community.

In surveys and focus groups, students reported high satisfaction with coaching in measures of the three program aims. They appreciated coaches' availability and guidance for the range of academic, personal, career, and other questions they had throughout medical school. Students endorsed the value of a longitudinal relationship and coaches' ability to meet their changing needs over time. Students rated coaches' teaching of foundational clinical skills highly. Students observed coaches learning some clinical skills with them - skills outside a coach's daily practice. Students also raised some concerns about variability among coaches. Attention to wellbeing and belonging to a learning community were program highlights for students. Coaches benefited from relationships with students and other coaches and welcomed the professional development to equip them to support all student needs.

Students perceive that a comprehensive medical student coaching program can achieve aims to promote their development and provide support. Within a non-evaluative longitudinal coach relationship, students build skills in driving their own learning and improvement. Coaches experience a satisfying yet challenging role. Ongoing faculty development within a coach community and funding for the role seem essential for coaches to fulfill their responsibilities.

"It Changed How I Think"-Impact of Programmatic Assessment Upon Practicing Physicians: A Qualitative Study

Programmatic assessment is a systematic approach used to document and assess learner performance. It offers learners frequent formative feedback from a variety of contexts and uses both high- and low-stakes assessments to determine student progress. Existing research has explored learner and faculty perceptions of programmatic assessment, reporting favorable impact on faculty understanding of the importance of assessment stakes and feedback to learners while students report the ability to establish and navigate towards goals and reflect on their performance. The Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve University adopted programmatic assessment methods at its inception. With more than 18 years' experience with programmatic assessment and a portfolio-based assessment system, CCLCM is well-positioned to explore its graduates' perceptions of their programmatic assessment experiences during and after medical school. In 2020, the investigators interviewed 26 of the 339 physician graduates. Participants were purposefully sampled to represent multiple class cohorts (2009-2019), clinical specialties, and practice locations. The investigators analyzed interview transcripts using thematic analysis informed by the frameworks of self-determination theory and professional identity formation. The authors identified themes and support each with participant quotes from the interviews. Based on findings, the investigators compiled a series of recommendations for other institutions who have already or plan to incorporate elements of programmatic assessment into their curricula. The authors concluded by discussing future directions for research and additional avenues of inquiry.

Combining Support and Assessment in Health Professions Education: Mentors' and Mentees' Experiences in a Programmatic Assessment Context

Introduction

Mentors in programmatic assessment support mentees with low-stakes feedback, which often also serves as input for high-stakes decision making. That process potentially causes tensions in the mentor-mentee relationship. This study explored how undergraduate mentors and mentees in health professions education experience combining developmental support and assessment, and what this means for their relationship.

Methods

The authors chose a pragmatic qualitative research approach and conducted semi-structured vignette-based interviews with 24 mentors and 11 mentees that included learners from medicine and the biomedical sciences. Data were analyzed thematically.

Results

How participants combined developmental support and assessment varied. In some mentor-mentee relationships it worked well, in others it caused tensions. Tensions were also created by unintended consequences of design decisions at the program level. Dimensions impacted by experienced tensions were: relationship quality, dependence, trust, and nature and focus of mentoring conversations. Mentors and mentees mentioned applying various strategies to alleviate tensions: transparency and expectation management, distinguishing between developmental support and assessment, and justifying assessment responsibility.

Discussion

Combining the responsibility for developmental support and assessment within an individual worked well in some mentor-mentee relationships, but caused tensions in others. On the program level, clear decisions should be made regarding the design of programmatic assessment: what is the program of assessment and how are responsibilities divided between all involved? If tensions arise, mentors and mentees can try to alleviate these, but continuous mutual calibration of expectations between mentors and mentees remains of key importance.

"What kind of doctor do you want to become?": Clinical supervisors' perceptions of their roles in the professional identity formation of General Practice residents

PURPOSE

Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents.

MATERIALS AND METHODS

Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts.

RESULTS

Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process.

CONCLUSIONS

To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF.

Mindset and Reflection—How to Sustainably Improve Intra- and Interpersonal Competences in Medical Education

Intra- and interpersonal competences (IICs) are essential for medical expertise. However, the effects of current medical curricula seem to not be sustainable enough, even though poorly trained IICs have negative effects on medical practice. A defensive attitude towards openly addressing personal–professional challenges seems to hinder a sustainable implementation of IICs training. Therefore, this study asks about the changeability of IICs and target factors of their implementation in medical education. The aim was to detect factors for the sustainable implementation of IICs in medical education from medical and non-medical perspectives. For this purpose, a total of 21 experts were interviewed. The interview material was analysed according to grounded theory principles to generate core categories to answer the research questions. As a first result, analysis revealed that IICs are changeable and developable, not in all, but in many students. It also showed four central prerequisites for successful implementation: the longitudinal integration of reflection and feedback in medical education and practice; a clear framework and individual path of education; the students’ mindset to develop themselves on a personal level; as well as the superiors’ mindset to openly deal with personal challenges in low hierarchies. Contrasting Carol Dweck’s mindset concept with our findings supports our theory that the development of a mindset which allows an open approach to personal deficits and challenges seems to be of central importance for both students and teachers. Two key factors in this process might be teaching about the impact of mindsets on learning and the willingness of superiors to openly address their personal challenges. To improve IICs in medical professionals, it seems helpful to pay more attention to the development of mindsets. Educating teachers and superiors about targeting factors could be a feasible direction for sustainable implementation.

How progress evaluations are used in postgraduate education with longitudinal supervisor-trainee relationships: a mixed method study

The combination of measuring performance and giving feedback creates tension between formative and summative purposes of progress evaluations and can be challenging for supervisors. There are conflicting perspectives and evidence on the effects supervisor-trainee relationships have on assessing performance. The aim of this study was to learn how progress evaluations are used in postgraduate education with longitudinal supervisor-trainee relationships. Progress evaluations in a two-year community-pharmacy specialization program were studied with a mixed-method approach. An adapted version of the Canadian Medical Education Directives for Specialists (CanMEDS) framework was used. Validity of the performance evaluation scores of 342 trainees was analyzed using repeated measures ANOVA. Semi-structured interviews were held with fifteen supervisors to investigate their response processes, the utility of the progress evaluations, and the influence of supervisor-trainee relationships. Time and CanMEDS roles affected the three-monthly progress evaluation scores. Interviews revealed that supervisors varied in their response processes. They were more committed to stimulating development than to scoring actual performance. Progress evaluations were utilized to discuss and give feedback on trainee development and to add structure to the learning process. A positive supervisor-trainee relationship was seen as the foundation for feedback and supervisors preferred the roles of educator, mentor, and coach over the role of assessor. We found that progress evaluations are a good method for directing feedback in longitudinal supervisor-trainee relationships. The reliability of scoring performance was low. We recommend progress evaluations to be independent of formal assessments in order to minimize roles-conflicts of supervisors.

Professional identity formation: linking meaning to well-being

Trainee distress and burnout continue to be serious concerns for educational programs in medicine, prompting the implementation of numerous interventions. Although an expansive body of literature suggests that the experience of meaning at work is critical to professional wellbeing, relatively little attention has been paid to how this might be leveraged in the educational milieu. We propose that professional identity formation (PIF), the process by which trainees come to not only attain competence, but additionally to "think, act and feel" like physicians, affords us a unique opportunity to ground trainees in the meaningfulness of their work. Using the widely accepted tri-partite model of meaning, we outline how this process can contribute to wellbeing. We suggest strategies to optimize the influence of PIF on wellbeing, offering curricular suggestions, as well as ideas regarding the respective roles of communities of practice, teachers, and formative educational experiences. Collectively, these encourage trainees to act as intentional agents in the making of their novel professional selves, anchoring them to the meaningfulness of their work, and supporting their short and long-term wellbeing.

Goal co-construction and dialogue in an internal medicine longitudinal coaching programme

BACKGROUND

Longitudinal coaching in residency programmes is becoming commonplace and requires iterative and collaborative discussions between coach and resident, with the shared development of goals. However, little is known about how goal development unfolds within coaching conversations over time and the effects these conversations have. We therefore built on current coaching theory by analysing goal development dialogues within resident and faculty coaching relationships.

METHODS

This was a qualitative study using interpretive description methodology. Eight internal medicine coach-resident dyads consented to audiotaping coaching meetings over a 1-year period. Transcripts from meetings and individual exit interviews were analysed thematically using goal co-construction as a sensitising concept.

RESULTS

Two themes were developed: (i) The content of goals discussed in coaching meetings focused on how to be a resident, with little discussion around challenges in direct patient care, and (ii) co-construction mainly occurred in how to meet goals, rather than in prioritising goals or co-constructing new goals.

CONCLUSIONS

In analysing goal development in the coach-resident relationships, conversations focused mainly around how to manage as a resident rather than how to improve direct patient care. This may be because academic coaching provides space separate from clinical work to focus on the stage-specific professional identity development of a resident. Going forward, focus should be on how to optimise longitudinal coaching conversations to ensure co-regulation and reflection on both clinical competencies and professional identity formation.

Productive struggle and failing safely: implications for developing adaptive expertise in communication

Navigating difficult conversations is a complex task that requires flexible and adaptive approaches. Residents developing this skill may initially struggle or fail, and require support. However, this experience may prepare residents for future learning which is essential to adaptive expertise. Limited understanding of how residents learn from failure in the workplace restricts the ability to maximize its potential benefits. The purpose of this study was to explore the role failure plays in learning to navigate difficult conversations during workplace learning. A constructivist grounded theory study was conducted using semi-structured interviews of 13 physicians (subspecialty residents and newly graduated physicians) from a Division of Developmental Paediatrics between 2017 and 2018. The authors used constant comparative analysis to identify themes iteratively. Themes were identified both inductively and deductively using the conceptual framework of adaptive expertise. Through independently leading difficult conversations, physicians were able to recognize that the failure that occurred in these encounters, prompted them to generate new knowledge which led to deeper conceptual understanding, thus supporting development of adaptive expertise. However, participants indicated that staff physicians often protect residents from difficult conversations, which limits their opportunity to receive feedback and engage in learning. Residents participate in difficult conversations that challenge them to go beyond their existing knowledge. Providing residents with opportunity to lead difficult conversations with patients and families while being supported by staff supervisors, allows for struggling through learning, which leads to a deeper conceptual understanding and supports development of adaptive expertise.

Beyond Competency: A Student Perspective on Growth Through Clerkship Feedback

This article proposes a paradigm shift from the competency-based model of clerkship feedback using checklists to a coaching-based, action plan-oriented process that centers on individualized student-oriented goals. Using a student perspective, the authors examine the feedback literature and put forward a proposal to use an impact model whose emphasis is to improve the learning climate for students. Several techniques are reviewed which include goal generation and creation of dynamic action plans. By intentionally focusing on coaching relationships as a platform for feedback, the learners and mentors share goals and the result of feedback becomes action-based behaviors which may help negate personal attribution and bias in the feedback process.

A Critical Review of Professional Identity Formation Interventions in Medical Education

PURPOSE

Professional identity formation (PIF) can be defined as the integration of the knowledge, skills, values, and behaviors of a profession with one's preexisting identity and values. Several different, and sometimes conflicting, conceptualizations and theories about PIF populate the literature; applying these different theories in PIF curricula and pedagogic strategies can profoundly impact the PIF of future physicians. The authors conducted a critical review of the recent literature on PIF interventions in medical education to explore the conceptualizations of and theoretical approaches to PIF that underlie them.

METHOD

The authors searched articles on PIF educational interventions published in 5 major medical education journals between 2010 and March 2021. The articles' context and findings were extracted, analyzed, and summarized to identify conceptualizations and theoretical approaches to PIF.

RESULTS

The authors identified 43 studies examining medical education interventions aimed at influencing PIF. The majority of the studies (n = 31) focused on undergraduate medical education. Reflective writing and the use of narrative reflections were the dominant modes of student activity in PIF interventions, supporting the dominant individualist approach to PIF. Less commonly PIF was understood as a socialization process or as an active process with both individually and socially focused influences.

CONCLUSIONS

Relying on reflective writing as the intervention of choice to impact PIF feeds the dominant individualist perspective on PIF. An unintended consequence of this individualist orientation is that cultural problems embedded in the profession can become burdens for individual physicians to personally bear. Future education and research into PIF should account for theoretical preferences and the impact of these preferences.

Understanding the near-peer relationship: resident perspectives around a novel on-call workplace-based assessment

BACKGROUND

Workplace-based assessment (WBA) is a critical component of competency-based medical education (CBME), though literature on WBA for overnight call is limited. We evaluated a WBA tool completed by supervising subspecialty trainees on paediatric residents during subspecialty overnight call, for usefulness facilitating feedback/coaching in this setting.

METHODS

Web-based surveys were sent to residents pre- and post-WBA tool implementation monthly for four months (August-December 2018), exploring feedback frequency, Likert-scaled opinions of tool feasibility/usefulness facilitating feedback, and qualitative experiences. Assessor comments were categorized as actionable/non-actionable. Quantitative data was summarized using descriptive statistics. Qualitative data was coded to identify themes.

RESULTS

Total response rates averaged 41% (total 25 responses, average five respondents/12 residents on-call each month). Post-implementation (n = 16 responses), a non-sustained trend of increased Medical Expert feedback was observed. Residents were generally divided or disagreed on tool usefulness facilitating feedback and feasibility. Comments contained actionable feedback in < 10% of completed WBAs. Qualitative analysis revealed barriers to tool-facilitated coaching including: feedback quality and setting/environment, role of senior near-peer as assessor, interpersonal burden in encounters, and tool-specific issues.

CONCLUSIONS

Increasing frequency of WBA tool completion is not sufficient to achieve CBME goals. Factors impacting feedback/coaching within the resident/near-peer dyad must be addressed.

It's a 'two-way street': resident perspectives of effective coaching relationships in the clinical learning environment

BACKGROUND

Coaching has gained traction in postgraduate medical education to enhance interactions between residents and clinical teachers, but these relationships present unique challenges and tensions. In order to realize the promises of coaching in medical education, we must understand how coaching relationships can be enacted to optimize resident development. The purpose of this study was to explore residents' perceptions of key characteristics for effective clinical teacher-resident (CT-R) coaching relationships.

METHODS

We conducted four focus groups and eight interviews with residents at a Canadian academic center. Using a social constructionist approach, focus groups and interviews were audio recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Residents described three main characteristics that contributed to effective CT-R coaching relationships: safe, meaningful, and collaborative. Residents emphasized that these characteristics needed to be bidirectional in nature to be most effective, in that both the resident and clinical teacher embodied these characteristics.

CONCLUSIONS

Residents identified that effective coaching relationships were shaped not only by clinical teacher behaviours, but importantly, the quality of the interpersonal relationship that was fostered. Thus, it is imperative to consider the bidirectional nature of the CT-R coaching relationship when striving to enhance resident development.

General practice residents’ perspectives on their professional identity formation: a qualitative study

Objectives

To move beyond professionalism as a measurable competency, medical educators have highlighted the importance of forming a professional identity, in which learners come to ‘think, act, and feel like physicians’. This socialisation process is known as professional identity formation (PIF). Few empirical studies on PIF in residency have been undertaken. None of these studies focused on PIF during the full length of GP training as well as the interplay of concurrent socialising factors. Understanding the socialisation process involved in the development of a resident’s professional identity and the roles of influencing factors and their change over time could add to a more purposeful approach to PIF. Therefore, we aimed to investigate the process of PIF during the full length of General Practice (GP) training and which factors residents perceive as influential.

Design

A qualitative descriptive study employing focus group interviews.

Setting

Four GP training institutes across the Netherlands.

Participants

Ninety-two GP residents in their final training year participated in 12 focus group interviews.

Results

Study findings indicated that identity formation occurs primarily in the workplace, as residents move from doing to becoming and negotiate perceived norms. A tapestry of interrelated influencing factors—most prominently clinical experiences, clinical supervisors and self-assessments—changed over time and were felt to exert their influence predominantly in the workplace.

Conclusions

This study provides deeper empirical insights into PIF during GP residency. Doing the work of a GP exerted a pivotal influence on residents’ shift from doing as a GP to thinking, acting and feeling like a GP, that is, becoming a GP. Clinical supervisors are of utmost importance as role models and coaches in creating an environment that supports residents’ PIF. Implications for practice include faculty development initiatives to help supervisors be aware of how they can perform their various roles across different PIF stages.

The Senior Medical Resident's New Role in Assessment in Internal Medicine

PURPOSE

With the introduction of competency-based medical education, senior residents have taken on a new, formalized role of completing assessments of their junior colleagues. However, no prior studies have explored the role of near-peer assessment within the context of entrustable professional activities (EPAs) and competency-based medical education. This study explored internal medicine residents' perceptions of near-peer feedback and assessment in the context of EPAs.

METHOD

Semistructured interviews were conducted from September 2019 to March 2020 with 16 internal medicine residents (8 first-year residents and 8 second- and third-year residents) at the University of Toronto, Toronto, Ontario, Canada. Interviews were conducted and coded iteratively within a constructivist grounded theory approach until sufficiency was reached.

RESULTS

Senior residents noted a tension in their dual roles of coach and assessor when completing EPAs. Senior residents managed the relationship with junior residents to not upset the learner and potentially harm the team dynamic, leading to the documentation of often inflated EPA ratings. Junior residents found senior residents to be credible providers of feedback; however, they were reticent to find senior residents credible as assessors.

CONCLUSIONS

Although EPAs have formalized moments of feedback, senior residents struggled to include constructive feedback comments, all while knowing the assessment decisions may inform the overall summative decision of their peers. As a result, EPA ratings were often inflated. The utility of having senior residents serve as assessors needs to be reexamined because there is concern that this new role has taken away the benefits of having a senior resident act solely as a coach.

"Fun slipping into the doctor's role"-The relationship between sonoanatomy teaching and professional identity formation before and during the Covid-19 pandemic

The various psychological dimensions of professional identity formation (PIF) are an important aspect of the study course for undergraduate medical students. Anatomical learning environments have been repeatedly shown to play a critical role in forming such an identity; however, relevance of PIF during sonoanatomical training remains underexplored. At the end of their basic anatomy studies, third-semester medical students took part in a four-day block course on anatomy and imaging. Anatomical content was revised in small groups using peer teaching and imaging methods, including one hour of hands-on sonoanatomy sessions each day. On-site sonoanatomy was identified as an excellent format to support students' transition from the pre-clinical to clinical phase as medical experts-to-be. Students enjoyed practical exercises and the clinical input, which increased their interest in the medical profession and their academic studies. This study further examined the effects of the transition into an online-only format, necessitated by the current Covid-19 pandemic. A comparison was made between the quantitative and qualitative evaluation data, and the written results of examinations of several on-site (n = 1096, mean age = 22.4 years ± 2.18), and online-only cohorts (n = 230, mean age = 22.6 years ± 2.21). The online-only transition led to a reduction of all PIF-related variables measured, losing identity-related variables, increasing students' stress levels, and reducing their long-term academic performance. Together, this study demonstrates presence of PIF in undergraduate sonoanatomy teaching, and cautions against the uncritical online-only substitution of hands-on learning environments.

Competency-Based Medical Education: Considering Its Past, Present, and a Post-COVID-19 Era

Advancement toward competency-based medical education (CBME) has been hindered by inertia and a myriad of implementation challenges, including those associated with assessment of competency, accreditation/regulation, and logistical considerations. The COVID-19 pandemic disrupted medical education at every level. Time-in-training sometimes was shortened or significantly altered and there were reductions in the number and variety of clinical exposures. These and other unanticipated changes to existing models highlighted the need to advance the core principles of CBME. This manuscript describes the impact of COVID-19 on the ongoing transition to CBME, including the effects on training, curricular, and assessment processes for medical school and graduate medical education programs. The authors outline consequences of the COVID-19 disruption on learner training and assessment of competency, such as conversion to virtual learning modalities in medical school, redeployment of residents within health systems, and early graduation of trainees based on achievement of competency. Finally, the authors reflect on what the COVID-19 pandemic taught them about realization of CBME as the medical education community looks forward to a postpandemic future.

Reframing professional identity through navigating tensions during residency: A qualitative study

INTRODUCTION

Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training.

METHODS

Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data.

RESULTS

Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training.

DISCUSSION

The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities.

Unobserved Observers: Nurses' Perspectives About Sharing Feedback on the Performance of Resident Physicians

PURPOSE

Postgraduate training programs are incorporating feedback from registered nurses (RNs) to facilitate holistic assessments of resident performance. RNs are a potentially rich source of feedback because they often observe trainees during clinical encounters when physician supervisors are not present. However, RN perspectives about sharing feedback have not been deeply explored. This study investigated RN perspectives about providing feedback and explored the facilitators and barriers influencing their engagement.

METHOD

Constructivist grounded theory methodology was used in interviewing 11 emergency medicine and 8 internal medicine RNs at 2 campuses of a tertiary care academic medical center in Ontario, Canada, between July 2019 and March 2020. Interviews explored RN experiences working with and observing residents in clinical practice. Data collection and analysis were conducted iteratively. Themes were identified using constant comparative analysis.

RESULTS

RNs felt they could observe authentic day-to-day behaviors of residents often unwitnessed by supervising physicians and offer unique feedback related to patient advocacy, communication, leadership, collaboration, and professionalism. Despite a strong desire to contribute to resident education, RNs were apprehensive about sharing feedback and reported barriers related to hierarchy, power differentials, and a fear of overstepping professional boundaries. Although infrequent, a key stimulus that enabled RNs to feel safe in sharing feedback was an invitation from the supervising physician to provide input.

CONCLUSIONS

Perceived hierarchy in academic medicine is a critical barrier to engaging RNs in feedback for residents. Accessing RN feedback on authentic resident behaviors requires dismantling the negative effects of hierarchy and fostering a collaborative interprofessional working environment. A critical step toward this goal may require supervising physicians to model feedback-seeking behavior by inviting RNs to share feedback. Until a workplace culture is established that validates nurses' input and creates safe opportunities for them to contribute to resident education, the voices of nurses will remain unheard.

Clinical teachers' professional identity formation: an exploratory study using the 4S transition framework

OBJECTIVES

The aim of this study was to explore factors that may influence the formation of professional identity in clinical teachers, specifically during the transition period from practitioner to teacher.

METHODS

This was a descriptive qualitative study. We used Schlossberg's 4S framework to explore influential factors comprised of the following: situation, self, support, and strategies. This study was conducted in teaching hospitals of a relatively new private medical school in Bali, a province in Indonesia. The participants were 30 clinical teachers who were selected using a maximum variation sampling strategy based on length of work experience, gender, specific educational roles as coordinators, and clinical specialty. Data were derived from three focus-group discussions and 13 in-depth interviews. A thematic analysis method was used to analyse the data.

RESULTS

The thematic analysis revealed that 12 subthemes related to the 4S framework influenced the development of clinical teachers' identity. It was also shown that reflective ability and community of practice, which was included in the self and strategy factors, respectively, were the two most important factors during the transition period in the development of professional identity.

CONCLUSIONS

Factors, both within and outside the self, can either support or hinder the formation of professional identity in clinical teachers. We suggest that when faculty development programs are designed, these factors should be incorporated, such as including a community of practice as part of the formal faculty development programs and the development of a teaching portfolio that nurtures reflective practice.

The promise of a health professions education imagination

CONTEXT

Social factors play a key role in health professions education and are thus a foundational topic that medical trainees must be taught. Although medical educators have discussed the best ways to teach these concepts for decades, there are still significant barriers to full incorporation of 'the social' into medical training.

FRAMEWORK

Building upon previous scholarship in medical education, the author argues for the development in trainees of a 'health professions education imagination' or a unique 'quality of mind' that facilitates navigating competing ways of knowing. This concept borrows explicitly from 'the sociological imagination', which is briefly described. Next, some of the principles of thinking that might contribute to a similar 'imagination' in health professions education are identified. Finally, exemplars are provided highlighting how recent scholars have used their health professions education imaginations in recent research and teaching practice.

IMPLICATIONS

The health professions education imagination provides a useful framework to help guide clinical and research trainees to integrate the epistemologically diverse forms of knowledge they are exposed to and to break down the silos that these forms of knowledge are commonly taught within.

Feedback and coaching

If used thoughtfully and with intent, feedback and coaching will promote learning and growth as well as personal and professional development in our learners. Feedback is an educational tool as well as a social interaction between learner and supervisor, in the context of a respectful and trusting relationship. It challenges the learner's thinking and supports the learner's growth. Coaching is an educational philosophy dedicated to supporting learners' personal and professional development and growth and supporting them to reach their potential. In clinical education, feedback is most effective when it is explicitly distinguished from summative assessment. Importantly, feedback should be about firsthand observed behaviors (which can be direct or indirect) and not about information which comes from a third party. Learners are more receptive to feedback if it comes from a source that they perceive as credible, and with whom they have developed rapport. The coaching relationship between learner and supervisor should also be built on mutual trust and respect. Coaching can be provided in the moment (feedback on everyday clinical activities that leads to performance improvement, even with short interaction with a supervisor) and over time (a longer term relationship with a supervisor in which there is reflection on the learner's development and co-creation of new learning goals). Feedback and coaching are most valuable when the learner and teacher exhibit a growth mindset. At the organizational level, it is important that both the structures and training are in place to ensure a culture of effective feedback and coaching in the clinical workplace.Conclusions: Having a thoughtful and intentional approach to feedback and coaching with learners, as well as applying evidence-based principles, will not only contribute in a significant way to their developmental progression, but will also provide them with the tools they need to have the best chance of achieving competence throughout their training. What is Known: • Feedback and coaching are key to advancing the developmental progression of trainees as they work towards achieving competence. • Feedback is not a one-way delivery of specific information from supervisor to trainee, but rather a social interaction between two individuals in which trust and respect play a key role. • Provision of effective feedback may be hampered by confusing formative (supporting trainee learning and development) and summative (the judgment that is made about a trainee's level of competence) purposes. What is New: • Approaches to both the provision of feedback/coaching and the assessment of competence must be developed in parallel to ensure success in clinical training programs. • Faculty development is essential to provide clinical teachers with the skills to provide effective feedback and coaching. • Coaching's effectiveness relies on nurturing strong trainee-supervisor relationships, ensuring high-quality feedback, nourishing a growth mindset, and encouraging an institutional culture that embraces feedback and coaching.

Autonomy and developing physicians: Reimagining supervision using self-determination theory

In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.

Does a measure of Medical Professional Identity Formation predict communication skills performance?

OBJECTIVE

To validate an approach to measuring professional identity formation (PIF), we explore if the Professional Identity Essay (PIE), a stage score measure of medical professional identity (PI), predicts clinical communication skills.

METHODS

Students completed the PIE during medical school orientation and a 3-case Objective Structured Clinical Exam (OSCE) where standardized patients reliably assessed communication skills in 5 domains. Using mediation analyses, relationships between PIE stage scores and communication skills were explored.

RESULTS

For the 351 (89%) consenting students, controlling for individual characteristics, there were increases in patient counseling (6.5%, p<0.01), information gathering (4.3%, p = 0.01), organization and management (4.1%, p = 0.02), patient assessment (3.6%, p = 0.04), and relationship development (3.5%, p = 0.03) skills for every half stage increase in PIE score. The communication skills of lower socio-economic status (SES) students are indirectly impacted by their slightly higher PIE stage scores.

CONCLUSION

Higher PIE stage scores are associated with higher communication skills and lower SES.

PRACTICE IMPLICATIONS

PIE predicts critical clinical skills and identifies how SES and other characteristics indirectly impact future clinical performance, providing validity evidence for using PIE as a tool in longitudinal formative academic coaching, program and curriculum evaluation, and research.

Preceptoring, proctoring, mentoring, and coaching in surgery

Contemporary models of surgical education that are founded on sound educational theories and constructs need to be used across the continuum of professional development of surgeons starting with the first day of medical school, through surgery residency and fellowship training, to the last day of surgical practice. The highly learner-centered and individually-focused special interventions of preceptoring, proctoring, mentoring, and coaching should be linked to innovative competency-based education models to address the educational needs of learners at all levels, and especially of surgeons in practice to continually improve their knowledge, skills, and performance, with the aspirational goal of achieving expertise and mastery. Each of these interventions is distinct with its own unique characteristics, applications, and anticipated impact, which must be clearly recognized for the interventions to be used most effectively. Broad acceptance and adoption of the aforementioned special interventions require recognition of the value each brings to the learner and the educational program. Professional organizations should play a key role in designing innovative educational programs that include these interventions, supporting their integration into surgical education and surgical practice, and influencing changes in the cultures in surgery to facilitate broad adoption of these interventions.

The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education

In 2010, several key works in medical education predicted the changes necessary to train modern physicians to meet current and future challenges in health care, including the standardization of learning outcomes paired with individualized learning processes. The reframing of a medical expert as a flexible, adaptive team member and change agent, effective within a larger system and responsive to the community's needs, requires a new approach to education: competency-based medical education (CBME). CBME is an outcomes-based developmental approach to ensuring each trainee's readiness to advance through stages of training and continue to grow in unsupervised practice. Implementation of CBME with fidelity is a complex and challenging endeavor, demanding a fundamental shift in organizational culture and investment in appropriate infrastructure. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium developed and implemented CBME, including common challenges and successes. Critical supporting factors include adoption of the master adaptive learner construct, longitudinal views of learner development, coaching, and a supportive learning environment.

An act of performance: Exploring residents' decision-making processes to seek help

CONTEXT

Residents are expected to ask for help when feeling insufficiently confident or competent to act in patients' best interests. While previous studies focused on the perspective of supervisor-resident relationships in residents' help-seeking decisions, attention for how the workplace environment and, more specifically, other health care team members influence these decisions is limited. Using a sociocultural lens, this study aimed to explore how residents' decision-making processes to seek help are shaped by their workplace environment.

METHODS

Through a constructivist grounded theory methodology, we purposively and theoretically sampled 18 residents: 9 juniors (postgraduate year 1/2) and 9 seniors (postgraduate year 5/6) at Amsterdam University Medical Centers. Using semi-structured interviews, participating residents' decision-making processes to seek help during patient care delivery were explored. Data collection and analysis were iterative; themes were identified using constant comparative analysis.

RESULTS

Residents described their help-seeking decision-making processes as an 'act of performance': they considered how asking for help could potentially impact their assessments. They described this act of performance as the product of an internal 'balancing act' with at its core the non-negotiable priority for providing safe and high-quality patient care. With this in mind, residents weighed up demonstrating the ability to work independently, maintaining credibility and becoming an accepted member of the health care team when deciding to seek help. This 'balancing act' was influenced by sociocultural characteristics of the learning environment, residents' relationships with supervisors and the perceived approachability of other health care team members.

CONCLUSIONS

This study suggests that sociocultural forces influence residents to experience help-seeking as an act of performance. Especially, a safe learning environment resulting from constructive relationships with supervisors and the approachability of other health care team members lowered the barriers to seek help. Supervisors could address these barriers by having regular conversations with residents about when to seek help.

Resident impression management within feedback conversations: A qualitative study

INTRODUCTION

Medical education is moving to conceptualise feedback as a bidirectional learning conversation. Within this conversation, learners experience a tension between assessment and feedback. That perceived tension affects learners' outward performances. In this study, we aimed to characterise residents' experiences with this tension and its effect on learner authenticity within feedback conversations.

METHODS

In this constructivist grounded theory study, the authors were informed by Goffman's theory of impression management. During data analysis, Dweck's theory of mindset was adopted. The authors conducted semi-structured interviews with 15 internal medicine residents. Data collection and analysis were conducted iteratively, using constant comparison to identify themes coinciding with impression management and mindset, ultimately developing a theoretical model to help explain residents' responses to tensions within feedback conversations.

RESULTS

Residents constantly felt 'scrutinized', and this affected their engagement in feedback conversations. They staged a performance within those conversations, linked to their underlying mindset: growth or fixed. Growth mindset was characterised by a focus on development as a physician and was associated with asking questions and seeking opportunities for growth. Fixed mindset was characterised by a focus on achieving a favourable evaluation and was associated with a hesitation to ask questions when faced with uncertainty and admit opportunities for growth, because they were concerned about impression management. Context influenced mindset and impression management. Residents adopted a fixed mindset and managed impressions when they perceived the permanence or consequences of evaluations within feedback. Residents adopted a growth mindset when they trusted the supervisor.

DISCUSSION

Residents assess the context of feedback conversations, altering the authenticity of their behaviours. Context, including the perceptions of formal assessment and relationships with supervisors, affected residents' mindset and impression management. Providing space for relationship-building and clarifying the purpose and structure of assessment may be helpful in supporting effective learning conversations in graduate medical education.

Driving lesson or driving test? : A metaphor to help faculty separate feedback from assessment

Although there is consensus in the medical education world that feedback is an important and effective tool to support experiential workplace-based learning, learners tend to avoid the feedback associated with direct observation because they perceive it as a high-stakes evaluation with significant consequences for their future. The perceived dominance of the summative assessment paradigm throughout medical education reduces learners' willingness to seek feedback, and encourages supervisors to mix up feedback with provision of 'objective' grades or pass/fail marks. This eye-opener article argues that the provision and reception of effective feedback by clinical supervisors and their learners is dependent on both parties' awareness of the important distinction between feedback used in coaching towards growth and development (assessment for learning) and reaching a high-stakes judgement on the learner's competence and fitness for practice (assessment of learning). Using driving lessons and the driving test as a metaphor for feedback and assessment helps supervisors and learners to understand this crucial difference and to act upon it. It is the supervisor's responsibility to ensure that supervisor and learner achieve a clear mutual understanding of the purpose of each interaction (i.e. feedback or assessment). To allow supervisors to use the driving lesson-driving test metaphor for this purpose in their interactions with learners, it should be included in faculty development initiatives, along with a discussion of the key importance of separating feedback from assessment, to promote a feedback culture of growth and support programmatic assessment of competence.

Autonomy and professional identity formation in residency training: A qualitative study

CONTEXT

Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training.

METHODS

Using constructivist grounded theory, we conducted 23 semi-structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de-identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data.

RESULTS

Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making 'real decisions' for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care.

CONCLUSIONS

This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.