Learner Handover: Who Is It Really For?

"Praise in Public; Criticize in Private": Unwritable Assessment Comments and the Performance Information That Resists Being Written

PURPOSE

Written assessment comments are needed to archive feedback and inform decisions. Regrettably, comments are often impoverished, leaving performance-relevant information undocumented. Research has focused on content and supervisor's ability and motivation to write it but has not sufficiently examined how well the undocumented information lends itself to being written as comments. Because missing information threatens the validity of assessment processes, this study examined the performance information that resists being written.

METHOD

Two sequential data collection methods and multiple elicitation techniques were used to triangulate unwritten assessment comments. Between November 2022 and January 2023, physicians in Canada were recruited by email and social media to describe experiences with wanting to convey assessment information but feeling unable to express it in writing. Fifty supervisors shared examples via survey. From January to May 2023, a subset of 13 participants were then interviewed to further explain what information resisted being written and why it seemed impossible to express in writing and to write comments in response to a video prompt or for their own "unwritable" example. Constructivist grounded theory guided data collection and analysis.

RESULTS

Not all performance-relevant information was equally writable. Information resisted being written as assessment comments when it would require an essay to be expressed in writing, belonged in a conversation and not in writing, or was potentially irrelevant and unverifiable. In particular, disclosing sensitive information discussed in a feedback conversation required extensive recoding to protect the learner and supervisor-learner relationship.

CONCLUSIONS

When documenting performance information as written comments is viewed as an act of disclosure, it becomes clear why supervisors may feel compelled to leave some comments unwritten. Although supervisors can be supported in writing better assessment comments, their failure to write invites a reexamination of expectations for documenting feedback and performance information as written comments on assessment forms.

Is it gossip or feedback? Surgical attendings' perceptions of gossip within residency

OBJECTIVE

Gossip-evaluative talk about an absent third party-exists in surgical residency programs. Attending surgeons may engage in gossip to provide residents with feedback on performance, which may contribute to bias. Nevertheless, the perspectives of attending surgeons on gossip has not been studied.

DESIGN

In this qualitative study, semi-structured interviews about gossip in surgical training were conducted with attending surgeons. We performed a reflexive thematic analysis of transcripts with a grounded theory approach to describe attendings' perceptions of their role in gossip within surgical residency.

SETTING

Interviews were conducted from September 23, 2023, to November 27, 2023 via Zoom™.

PARTICIPANTS

Eighteen surgery attendings associated with 7 surgical training programs were interviewed.

RESULTS

Six themes were developed: 1) Attendings typically view gossip with a negative lens; thus, well-intended conversations about resident performance that meet the academic definition of gossip are not perceived as gossip; 2) Gossip can damage attendings' reputations as surgeons and educators; 3) Mitigating the negative impacts of gossip by maintaining accurate and objective standards of honest communication is hard; 4) Attendings express concerns about hearing other attendings' impressions of residents prior to formulating their own opinion; 5) The surgical hierarchy restricts the volume and content of gossip that reaches attendings, which may limit their knowledge of program culture; and 6) It is very difficult to mitigate gossip at the program level. Ultimately, attendings utilize gossip (e.g. triangulating their experience) with the goal of providing residents feedback.

CONCLUSIONS

Defining important conversations about resident performance as gossip should not discourage these critically important conversations but rather underscore the importance of combating harmful gossip through 3 behaviors: 1) committing to objective communication; 2) limiting or reframing information about resident performance that is shared with attendings who have yet to formulate their own opinions; and 3) regulating gossip in particular high-stakes microenvironments (e.g. the operating room).

Multifaceted Strategy That Improves Students' Achievement of Entrustable Professional Activities Across Advanced Pharmacy Practice Experiences

OBJECTIVE

To outline an approach to help students achieve Entrustable Professional Activities (EPAs) entrustment during a sequence of Advanced Pharmacy Practice Experiences (APPEs) by implementing longitudinal monitoring and individualized intervention and remediation strategies.

METHODS

Using the recommended EPAs within the core APPEs (acute care, ambulatory care, community, institutional), students were expected to achieve entrustment on all EPAs by graduation. A longitudinal monitoring approach, using an "EPA report card," was implemented to continuously identify students at risk of not meeting the EPA requirement of "Level 3" entrustment (perform with reactive supervision). Individualized interventions, including proactive outreach and in-sequence remediation, were incorporated into the APPE core and elective sequence to help ensure all students were entrusted by the end of APPEs without requiring further end-of-year remediation to graduate.

RESULTS

For the graduating classes of 2023 and 2024, 12% (8 of 69) and 16% (12 of 75) students, respectively, were identified as at risk of not meeting EPA entrustment. Proactive outreach, in-sequence remediation, or a combination of both strategies, were used to enhance learning and EPA performance. As a result, all students achieved "Level 3" entrustment on the deficient EPA(s) by the end of the APPE sequence. No student required further end-of-year remediation to graduate.

CONCLUSION

Utilizing a multifaceted strategy provided timely, real-world practice opportunities to improve the students' achievement of EPAs across the APPE curriculum and decreased the need for end-of-year remediation and potential graduation delays.

Protocol for a scoping review study on learning plan use in undergraduate medical education

BACKGROUND

The current paradigm of competency-based medical education and learner-centredness requires learners to take an active role in their training. However, deliberate and planned continual assessment and performance improvement is hindered by the fragmented nature of many medical training programs. Attempts to bridge this continuity gap between supervision and feedback through learner handover have been controversial. Learning plans are an alternate educational tool that helps trainees identify their learning needs and facilitate longitudinal assessment by providing supervisors with a roadmap of their goals. Informed by self-regulated learning theory, learning plans may be the answer to track trainees' progress along their learning trajectory. The purpose of this study is to summarise the literature regarding learning plan use specifically in undergraduate medical education and explore the student's role in all stages of learning plan development and implementation.

METHODS

Following Arksey and O'Malley's framework, a scoping review will be conducted to explore the use of learning plans in undergraduate medical education. Literature searches will be conducted using multiple databases by a librarian with expertise in scoping reviews. Through an iterative process, inclusion and exclusion criteria will be developed and a data extraction form refined. Data will be analysed using quantitative and qualitative content analyses.

DISCUSSION

By summarising the literature on learning plan use in undergraduate medical education, this study aims to better understand how to support self-regulated learning in undergraduate medical education. The results from this project will inform future scholarly work in competency-based medical education at the undergraduate level and have implications for improving feedback and supporting learners at all levels of competence.

SCOPING REVIEW REGISTRATION

Open Science Framework osf.io/wvzbx.

The Inconspicuous Learner Handover: An Exploratory Study of U.S. Emergency Medicine Program Directors' Perceptions of Learner Handovers from Medical School to Residency

Phenomenon: Central to competency-based medical education is the need for a seamless developmental continuum of training and practice. Trainees currently experience significant discontinuity in the transition from undergraduate (UME) to graduate medical education (GME). The learner handover is intended to smooth this transition, but little is known about how well this is working from the GME perspective. In an attempt to gather preliminary evidence, this study explores U.S. program directors (PDs) perspective of the learner handover from UME to GME. Approach: Using exploratory qualitative methodology, we conducted semi-structured interviews with 12 Emergency Medicine PDs within the U.S. from October to November, 2020. We asked participants to describe their current perception of the learner handover from UME to GME. Then we performed thematic analysis using an inductive approach. Findings: We identified two main themes: The inconspicuous learner handover and barrier to creating a successful UME to GME learner handover. PDs described the current state of the learner handover as "nonexistent," yet acknowledged that information is transmitted from UME to GME. Participants also highlighted key challenges preventing a successful learner handover from UME to GME. These included: conflicting expectations, issues of trust and transparency, and a dearth of assessment data to actually hand over. Insights: PDs highlight the inconspicuous nature of learner handovers, suggesting that assessment information is not shared in the way it should be in the transition from UME to GME. Challenges with the learner handover demonstrate a lack of trust, transparency, and explicit communication between UME and GME. Our findings can inform how national organizations establish a unified approach to transmitting growth-oriented assessment data and formalize transparent learner handovers from UME to GME.

The missing ingredient: Medical student insights to inform and enhance learner handover

BACKGROUND

Learner handover (LH) is the passing on of information about students between educators. In light of broad acceptance that LH can improve learner support experiences and performance outcomes, those involved are seeking greater governance to achieve practical, effective handover implementation. Stakeholder consultation can inform and enable the co-creation of meaningful, robust practice guidance. This study sought to address the gap in literature around in-depth learner opinion, a key element so far overlooked.

METHODS

This qualitative study (2022) investigated undergraduate medical student perspectives on appropriate tutor information-sharing at the University of Limerick School of Medicine (ULSoM). The findings build upon an educator focus group study published by the authors (2021). Eleven participants were recruited to represent the typical graduate-entry medical school programme population across years 1-4 of study. Their understanding and expectations of "learner handover" were explored qualitatively, using online, individual, semi-structured interviews. Inductive transcript coding and thematic data analysis were applied to illustrate learner insights.

FINDINGS

Emergent themes included shared values, individual context and collaborative process, with ideas proposed for specific action around student education, staff training, mental health support, and documented procedures.

DISCUSSION

Consent, system transparency, data security and the development of positive handover culture were revealed as current needs. Student perspectives, together existing LH literature and highlighted aspects of educational theory, allowed the creation a new conceptual LH framework as a foundation for practice improvement.

CONCLUSION

These findings provide clarity and contextual understanding, mainly from a pre-clinical phase learner standpoint, with pragmatic suggestions to enhance LH appeal.

Having a Bad Day Is Not an Option: Learner Perspectives on Learner Handover

PURPOSE

Learner handover is the sharing of learner-related information between supervisors involved in their education. The practice allows learners to build upon previous assessments and can support the growth-oriented focus of competency-based medical education. However, learner handover also carries the risk of biasing future assessments and breaching learner confidentiality. Little is known about learner handover's educational impact, and what is known is largely informed by faculty and institutional perspectives. The purpose of this study was to explore learner handover from the learner perspective.

METHOD

Constructivist grounded theory was used to explore learners' perspectives and beliefs around learner handover. Twenty-nine semistructured interviews were completed with medical students and residents from the University of Ottawa and University of California, San Francisco. Interviews took place between April and December 2020. Using the constant comparative approach, themes were identified through an iterative process.

RESULTS

Learners were generally unaware of specific learner handover practices, although most recognized circumstances where both formal and informal handovers may occur. Learners appreciated the potential for learner handover to tailor education, guide entrustment and supervision decisions, and support patient safety, but worried about its potential to bias future assessments and breach confidentiality. Furthermore, learners were concerned that information-sharing may be more akin to gossip rather than focused on their educational needs and feared unfair scrutiny and irreversible long-term career consequences from one shared mediocre performance. Altogether, these concerns fueled an overwhelming pressure to perform.

CONCLUSIONS

While learners recognized the rationale for learner handover, they feared the possible inadvertent short- and long-term impact on their training and future careers. Designing policies that support transparency and build awareness around learner handover may mitigate unintended consequences that can threaten learning and the learner-supervisor relationship, ensuring learner handover benefits the learner as intended.

Revisiting Feed Forward: Promoting a Student-Centered Approach to Education Handoffs, Remediation, and Clerkship Success

Issue: Throughout medical school, and especially during clerkships, students experience changing work and learning environments and are exposed to new academic, interpersonal, and professional challenges unique to clinical learning. Given the siloed nature of clinical rotations, students often "fall through the cracks" and may repeatedly struggle through clerkships without support and coaching from which they would otherwise benefit. Many institutions have grappled with creating feed forward processes, that is, educational handoffs in which information is shared among faculty about struggling students with the intention of providing longitudinal support to ensure their success, while protecting students from negative bias that may follow them throughout the remainder of their medical school tenure. Evidence: Here, the authors describe the feed forward processes of four medical schools. Each school's process relies on close collaboration between course directors and deans to identify students and develop intervention plans. Course leadership and administration are typically the primary drivers for long-term follow-up with students. The number of participants in the process varies, with only one school directly involving students. Two schools hold larger, regularly scheduled meetings with up to 12 faculty present in their institution's feed forward process. Across these institutions, students can "graduate" from the feed forward process once they achieve competency in the areas of concern. Implications: The authors believe the most important outcome achieved is the formalization and adherence to a feed forward process. Thus, risk to students in the form of negative bias is mitigated by the flow of information, the extent to which information is available, and permitting students to be part of the process. These exemplars give insight into variable approaches to feed forward systems adopted by medical schools and demonstrate highly visible methodologies by which educational leadership empower students and educators toward a shared goal of student progress and achievement.

The Power of One Word to Paint a Halo or a Horn: Demonstrating the Halo Effect in Learner Handover and Subsequent Evaluation

PURPOSE

Learner evaluation based upon direct observation is a cornerstone of modern competency-based medical education. Learner handover has become a widely accepted practice. Cognitive attribution bias is a potential threat to the validity of learner evaluation following learner handover.

METHOD

In this 2 x 2 (learner handover: halos/horns x learner gender: man/woman) factorial, nonequivalent comparison group experimental design, registered attendees at a national medical education conference watched 1 of 2 videos (depicting a woman learner or man learner) of simulated learner-patient encounters. Data were collected on April 30 and May 1, 2022. Participants received learner handover conditioning before watching the video. The conditioning was randomized to suggest the learner they were about to watch was either "above-average" (halos) or "below-average" (horns). Following the video, participants completed an evaluation form.

RESULTS

Participants rated the learner in a video encounter preceded by a horns statement significantly lower than the learner in a video encounter preceded by a halo statement, F (1,65) = 10.15, P < .01, η 2 = .14, horns mean adj = 12.49 (CI 11.34, 13.63), halo mean adj = 15.10 (CI 13.93, 16.28). This represented a scoring difference of 2.61 points on a 30-point scale. More years of teaching experience was negatively associated with the score, F (1,65) = 13.44, P < .001, η 2 = .17.

CONCLUSIONS

Learner conditioning differing by a single word, labeling a learner as either "above-average" or "below-average" resulted in a large difference in scoring by medical educators.

Effects of informal learner handover in clinical dental education

BACKGROUND

It is currently under discussion whether Learner Handovers (LH) are beneficial, disadvantageous, or useful in Health Professions Education. Research has not been conducted to determine the extent of existing informal learner handover (ILH) through faculty discussions. In addition to providing stakeholders with added context, examining the nature of ILH may also provide insight into the bias associated with Learner Handover.

METHODS

Transcripts from a series of semi-structured Focus Group Discussions (FGDs) and interviews (from January to March 2022) were iteratively reviewed to identify relevant patterns and correlations. The study involved the voluntary participation of 16 active clinical dental faculty members with a variety of designations. We did not discard any opinions.

RESULTS

It was found that ILH had a mild impact on students' training. ILH effects can be categorized into four key areas: (1) faculty behavior with students, (2) faculty expectations from students, 3) teaching approach, and 4) faculty feedback practices. Furthermore, five additional factors were identified as having a greater influence on ILH practices.

CONCLUSIONS

In clinical dental training, ILH has a minor effect on faculty-student interactions. Faculty perceptions and ILH are strongly influenced by other factors contributing to the student's 'academic reputation. As a result, student-faculty interactions are never free of prior influences, so stakeholders need to take them into consideration when creating a formal LH.

Is there a role for a learner education handover as part of the Medical Council of Canada assessment and licensing process?

The transition from undergraduate medical education (UGME) to postgraduate medical education (PGME) is a time of vulnerability for medical schools, postgraduate residency programs, and most importantly, traineesThere is a disconnect between the UGME and PGME experience. Student information shared by UGME is primarily summative of knowledge and skills; PGME programs are unaware of specific learner accommodation requirements, tailored supervisory needs, or potential professionalism concerns identified during UGMEThis lack of integration between UGME and PGME increases potential risk to learners, postgrad programs and patientsBetter linkages and communication along the education continuum could optimize learning and reduce inefficiency and riskThe Medical Council of Canada (MCC) has asked if there is a role for a learner handover (LH) within their licensing processes; however the intended purpose of an LH must first be determinedA Canadian-based LH referred to as a Learner Education Handover (LEH) model including disclosure of student learning/disability accommodation needs, general health concerns, EDI/religious requirements, professionalism concerns, and recommendations for special focus in residency of specific areas of medical knowledge/skill is described.Findings from beta and pilot testing support the value and feasibility of the LEH model. Fundamental principles are outlined: LEH occurs post-residency matchLEH should be forward facing; focused on ongoing or recurring learner issues and needsLearners must be included in the processImplementation would require participation by all Canadian medical schools and all learnersImplementation challenges include: Ensuring learner safety following information disclosureEngaging UGME DeansProtection of information ensuring a 'need-to-know' status is maintainedIncorporating the LEH into the licensing activity could enable the MCC to support a system that proactively responds to learner needs, optimizes physician performance and promotes safe, high quality patient care.