Supported Independence: The Role of Supervision to Help Trainees Manage Uncertainty

A practical primer on clinical supervision of learners in the emergency department

Introduction

Effective supervision of learners in the clinical environment is essential for learner professional development and patient safety. Despite this importance, many supervising attendings receive little to no training around supervising learners. As faculty join emergency departments (EDs) at primary and affiliate training sites, it is essential to provide them with a framework to utilize when approaching learner supervision.

Methods

A workgroup of members from the Society for Academic Emergency Medicine (SAEM) Education Committee was formed to respond to a directive from the SAEM board to identify best practices for new clinician educators when supervising learners. Drawing on their experience and expertise in learner supervision, medical education, and faculty development, the members completed a literature search to identify best practices in supervision, with a special focus on the ED environment.

Analysis

The workgroup identified three domains that must be considered to provide effective supervision to learners: learner characteristics, supervisor characteristics, and clinical environment.

Recommendations

Implementing effective supervision in the clinical environment requires a multifaceted approach and consideration of factors for both the learner and the supervisor. Direct observation, supplemented by standardized assessment tools, is the preferred supervision method; however, the demands of our clinical environment may require supervisors to assess the learner's proficiency using other methods including informal knowledge assessments, inference from oral presentations, review of clinical documentation, feedback from patients themselves, procedural walkthroughs, and secondhand information from the health care or training team.

Ready, or not? A qualitative study of emergency medicine senior residents' perspectives on preparing for practice

Objectives

The transition from residency to unsupervised practice challenges doctors to adapt to new environments and responsibilities. Past work has focused on how physicians acclimate to their new roles, raising questions about how residents might think proactively about transitions while still in training. This study explores senior emergency medicine (EM) residents' perspectives on preparedness for unsupervised practice and how they draw from training experiences to assess their evolving sense of preparedness.

Methods

The authors used a constructivist grounded theory approach, inviting all fourth-year EM residents from two residency programs to participate in semistructured interviews. Participants were asked to reflect on their preparedness for entering unsupervised practice and to imagine scenarios for which they felt unprepared. Two authors coded line by line using constant comparison, organizing data into codes and categories. The research team met to discuss relationships between codes, developing themes to theorize about the phenomenon of interest.

Results

Sixteen residents were interviewed. The authors identified two overarching categories of themes. First, participants described individualized conceptualizations of preparedness, constructed from past workplace experiences and those they anticipated they would have in unsupervised practice. These conceptualizations emphasized drawing confidence from experience and developing adaptability to manage the uncertainties of medical practice. The second overarching category involved participants' efforts to gauge their own preparedness. To do so, they used interactions with others to assess their readiness to manage specific problems and made holistic appraisals across multiple experiences to assess their overall preparedness for unsupervised practice.

Conclusions

Trainees draw from past experiences to forecast their abilities to manage the inevitable uncertainties of unsupervised practice. These conceptualizations of preparedness reflect a capability approach to training, with informed confidence and dynamic self-appraisal. These findings suggest potential learning goals of senior trainees and considerations for medical educators to consider when fostering trainees' capabilities for unsupervised practice.

"With Great Responsibility Comes Great Uncertainty"

BACKGROUND

Uncertainty is inherent in medicine, and trainees are particularly exposed to the adverse effects of uncertainty. Previous work suggested that junior residents seek to leverage the support of supervisors to regulate the uncertainty encountered in clinical placements. However, a broader conceptual framework addressing uncertainty experience, from the sources of uncertainty to residents' responses, is still needed.

OBJECTIVE

To capture the spectrum of uncertainty experiences in medical residents, providing an integrative framework that considers the influence of specialties and training stages on their experience with clinical uncertainty.

DESIGN

We used Hillen's uncertainty tolerance framework to conduct a thematic template analysis of individual and focus group interviews, identifying themes and subthemes reflecting residents' experience of clinical uncertainty.

PARTICIPANTS

Medical residents from diverse medical specialty training programs, across five French medical schools.

APPROACH

Qualitative study driven by an interpretivist research paradigm.

RESULTS

Twenty residents from all years of medical residency and diverse medical specialties were interviewed during three focus groups and five individual interviews. They described managing treatments, making ethical decisions, and communicating uncertainty, as their major sources of uncertainty. We identified residents' delayed response to uncertainty as a key theme, fostering the development of experiential learnings. Prior clinical experience was a key determinant of uncertainty tolerance in medical residents. Entrusting residents with responsibilities in patient management promoted their perception of self-efficacy, although situations of loneliness resulted in stress and anxiety.

CONCLUSION

Residents face significant uncertainty in managing treatments, ethical decisions, and communication due to limited clinical experience and growing responsibilities. Scaffolding their responsibilities and clearly defining their roles can improve their comfort with uncertainty. To that extent, effective supervision and debriefing are crucial for managing emotional impacts and fostering reflection to learn from their uncertain experiences.

Check, Please! Supervisor-Learner Dyads Using "Checking" for Clinical Support During Indirect Supervision

BACKGROUND

Indirect supervision is essential for granting autonomy to learners. Sometimes referred to as leaving the learner "unsupervised," there is growing recognition that learners and supervisors engage in clinical support through ongoing interactions, albeit at a distance.

OBJECTIVE

To understand how the complementary activities of asking for and providing clinical support at a distance come together as indirect supervision by identifying the natural language used between learners and supervisors.

DESIGN

A collective case study of 15 attending physician-senior medical resident dyads from 2018 to 2023. Each case consisted of 2 full days of ethnographic observation of the resident on an internal medicine clinical teaching unit in one of three metropolitan hospitals; 2 end of day interviews with each dyad member; and a third interview with the attending after the 2-week rotation.

PARTICIPANTS

Fifteen internal medicine residents (PGY-2 and PGY-3) who were scheduled to work for the first time with 15 attending physicians.

APPROACH

Data collection was iterative with deductive and inductive analysis to identify patterns of communication.

KEY RESULTS

The language of "checking," such as checkpoints, checking on, and checking in, was central to communications within dyads. Indirect supervision included attendings using scheduled checkpoints and backstage oversight activities to check on the senior resident's patient care while expecting residents to access their support, as needed, by checking-in with them. Residents checked in with their attending to relay patient information updates, ask questions, and hint at needing their plans doublechecked; these communications had similar formats making them difficult to distinguish but functioned to preserve resident independence while accessing clinical support.

CONCLUSIONS

Indirect supervision creates clinical support through ongoing communication between learners and supervisors at a distance. It is a collaborative process for mutual reassurance that safe patient care is being provided and that support is available when needed.

Critical Thinking in the Texting Age

OBJECTIVES

Though texting has become a preferred way for clinicians to discuss patient care, surgeons report that texting detracts from trainees' education. Little research has explored how texting relates to education and more specifically to critical thinking - the problem-solving and decision-making processes central to safe patient care. As such, we aimed to identify how trainees perceived the effect of texting on critical thinking.

DESIGN

We undertook a qualitative study using a constructivist paradigm. Through interviews, we explored the relationship between texting and critical thinking. We approached interview data with a directed content analysis, generated themes in discussion with the study team, and corroborated findings through member checking.

SETTING

We conducted this study at the University of California San Francisco.

PARTICIPANTS

Thirty surgical residents from multiple surgical specialties participated.

RESULTS

We identified four themes: a new technocultural norm, altered practice patterns and demands, de-emphasis of critical thinking, and methods to promote critical thinking skills. A new technocultural norm has fundamentally changed communication. Furthermore, broader changes in medicine have affected the setting in which teams work, leading to altered practice patterns and demands. Together, certain aspects of the new technocultural norm combined with altered practice patterns have de-emphasized critical thinking, shifting the balance in team relationships towards communication and away from critical thinking. After establishing the de-emphasis of critical thinking in the setting of texting, participants posited possible methods to promote critical thinking skills. These methods centered on changing feedback and team culture and providing structured education to junior and senior residents.

CONCLUSIONS

Although texting has become an enduring fixture in clinical communication, it may detract from critical thinking in certain scenarios. Educators can harness this study's findings to build structured education and change the culture around text-based communication to allow for efficient clinical care without sacrificing critical thinking.

Paths to learning: How residents navigate transience in supervisory relationships in the emergency department

Background

Strong relationships between trainees and physician supervisors can positively influence how trainees navigate workplace learning. How trainees act and learn in clinical workplaces characterized by rapidly developing and dissolving supervisory pairings is less well understood. This study uses the emergency department (ED) to examine the impact of transient supervisory relationships on how residents approach clinical learning opportunities.

Methods

We retrospectively analyzed pediatric and emergency medicine resident rotations in an urban, tertiary, academic pediatric ED between July 2018 and June 2022. Using social network analysis (SNA), we identified resident-attending dyads and patients seen by each dyad. This informed semistructured interviews to understand how transience in supervisory relationships influences how residents approach and interpret clinical experiences. With self-determination theory as an organizing framework, the investigators performed line-by-line coding with constant comparative analysis which supported subsequent theoretical coding.

Results

During the study, 526 residents completed 1013 rotations with 87 attendings. A mean (±SD) of 25 (±7) attendings supervised a resident per rotation, with dyads caring for a mean (±SD) of 4 (±4) patients. Twelve residents were interviewed and described different paths to learning depending on the transience of their relationships with clinical supervisors. More sustained contact presented an opportunity to build competence by fostering autonomy and feedback, while briefer contact advanced residents' competence by exposing them to variable practice patterns.

Conclusions

Combining SNA with qualitative analysis revealed that residents in the ED experience a spectrum of contact with attendings and perceive different paths to learning depending on the transience of this relationship. The results suggest different educational strategies may be necessary to maximize learning depending on the length or resident-attending interactions.

Residents' Communication With Attendings About Uncertainty: A Single-Site Longitudinal Survey

OBJECTIVE

Managing uncertainty is a core competency of pediatric residents. However, discussing uncertainty with attending physicians can be challenging. Research is needed to understand residents' goals when communicating about uncertainty with attending physicians and how residents' perceptions of communication change during residency. Therefore, we assessed changes in residents' perceptions of their own ability to communicate uncertainty and their perceptions of attending physicians' willingness to discuss uncertainty effectively. We also identify residents' goals and challenges communicating uncertainty.

METHODS

We conducted a 3-year (2018-2021) survey with 2 cohorts of residents at a US children's hospital. Of the 106 eligible residents, 100 enrolled and completed Phase I (94% response rate), 61 of the enrolled residents completed Phase II (61% response rate), and 53 completed Phase III (53% response rate). We employed hierarchical linear modeling to account for clustering of the data (Phases within residents) and to assess changes in communication efficacy and target efficacy over time. We coded open-ended responses to identify residents' communication goals and challenges.

RESULTS

Communication efficacy and target efficacy significantly increased over time. Open-ended responses indicated that residents managed multiple task, identity, and relational goals. Residents described persistent challenges related to wanting to appear competent and working with attending physicians who were unwilling to discuss uncertainty.

CONCLUSIONS

Although residents may grow more confident communicating uncertainty, such conversations are complex and can present challenges throughout residency. Our results support the value of training on communication about uncertainty, not only for residents, but also attending physicians.

'Walking together': How relationships shape physicians' clinical reasoning

INTRODUCTION

The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning.

METHODS

Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest.

RESULTS

The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts.

CONCLUSION

Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.

Towards a flexible and personalised development of veterinarians and veterinary nurses working in a companion animal referral care setting

In the Netherlands, the demand for veterinarians and veterinary nurses (VNs) working within referral care is rapidly growing and currently exceeds the amount of available board-certified specialists. Simultaneously, a transparent structure to guide training and development and to assess quality of non-specialist veterinarians and VNs working in a referral setting is lacking. In response, we developed learning pathways guided by an entrustable professional activity (EPA) framework and programmatic assessment to support personalised development and competence of veterinarians and VNs working in referral settings. Between 4 and 35 EPAs varying per discipline (n = 11) were developed. To date, 20 trainees across five disciplines have been entrusted. Trainees from these learning pathways have proceeded to acquire new EPAs in addition to their already entrusted set of EPAs or progressed to specialist training during (n = 3) or after successfully completing (n = 1) the learning pathway. Due to their outcome-based approach, the learning pathways support flexible ways of development.

"Everything new is happening all at once": a qualitative study of early career obstetrician and gynaecologists' preparedness for independent practice

Background

The transition from residency training into practice is associated with increasing risks of litigation, burnout, and stress. Yet, we know very little about how best to prepare graduates for the full scope of independent practice, beyond ensuring clinical competence. Thus, we explored the transition to independent practice (TTP) experiences of recent Obstetrics and Gynaecology graduates to understand potential gaps in their perceived readiness for practice.

Methods

Using constructivist grounded theory, we conducted semi-structured interviews with 20 Obstetricians/Gynaecologists who graduated from nine Canadian residency programs within the last five years. Iterative data collection and analysis led to the development of key themes.

Results

Five key themes encompassed different practice gaps experienced by participants throughout their transition. These practice gaps fit into five competency domains: providing clinical care, such as managing unfamiliar low-risk ambulatory presentations; navigating logistics, such as triaging referrals; managing administration, such as hiring or firing support staff; reclaiming personhood, such as boundary-setting between work and home; and bearing ultimate responsibility, such as navigating patient complaints. Mitigating factors were found to widen or narrow the extent to which new graduates experienced a practice gap. There was a shared sense among participants that some practice gaps were impossible to resolve during training.

Conclusions

Existing practice gaps are multi-dimensional and perhaps not realistically addressed during residency. Instead, TTP mentorship and training opportunities must extend beyond residency to ensure that new graduates are equipped for the full breadth of independent practice.

Having a Voice: Resident Perceptions of Supervision, Decision-Making and Patient Care Ownership

OBJECTIVE

Heightened resident supervision due to patient safety concerns is increasingly common in pediatrics and may leave residents with fewer opportunities for independent decision-making, a diminished sense of autonomy, and decreased engagement. This may ultimately threaten their development into competent clinicians. Understanding how pediatric residents experience supervision's influence on their involvement in decision-making, engagement in patient care, and learning is crucial to safeguard their transition to independent practice. In relation to supervision, our research investigated: 1) how residents navigated their involvement with clinical decision-making and 2) how opportunities to make clinical decisions influenced their engagement in patient care and learning.

METHODS

From 2019-2020, we recruited 38 pediatric residents from three different programs for a qualitative interview-based study. Through a constructivist stance, we explored clinical decision-making experiences and performed thematic analysis using an iterative and inductive process.

RESULTS

We identified three themes: 1) Residents perceived having autonomy when they had space to make independent decisions, regardless of supervisor's presence; 2) Patient care ownership resulted from having a voice in a variety of contributions to patient care; and 3) Supervisors' behaviors modulated patient care ownership and thereby residents' sense of feeling heard, their engagement in patient care, and their learning.

CONCLUSIONS

Our results suggest that focusing on patient care ownership may better fit with current learning environments than aiming for independence and autonomy. They provide insight on how, in the pediatric learning climate of enhanced supervision, supervisors can preserve resident engagement in patient care and learning by augmenting patient care ownership and ensuring residents have a voice.

Cherry-picking learning tasks in the orchard of postgraduate medical education - a socio-cultural perspective

'@ReneeStalmeijer and @SNEMeeuwissen use a socio‐cultural perspective, empirical examples, and the cherry‐picking metaphor, to explore interactions between trainees and healthcare teams that impact trainees’ selection of learning tasks during workplace learning

What the experts see: A qualitative analysis of the behaviors of master adaptive learners in emergency medicine

Objectives

The Master Adaptive Learner (MAL) model postulates that learners develop adaptive expertise through cycles of self-regulated learning. Despite a robust theoretical basis, the actual observable behaviors of MALs are not well characterized. We sought to define behaviors that characterize MALs within emergency medicine (EM) training.

Methods

Using a constructivist grounded theory approach, we analyzed semistructured interviews with expert EM educators. These experts reflected on observable behaviors as well as factors in the clinical learning environment that may modulate these behaviors. We recruited using purposive sampling until thematic saturation.

Results

We identified four overall themes, of which three described groups of learner behaviors and a fourth described modifiers of these behaviors. Learner behaviors include: (1) critical interrogation of practice, (2) intellectual risk-taking, and (3) intentional curation of a learning network. Critical interrogation of practice encompasses several observable behaviors including learner-driven feedback conversations, independent synthesis of clinical information, appropriate deviation from algorithms based on their conceptual understanding of core principles, intentional use of case variation and hypothetical questioning, and continuous refinement of decisions. MALs also engage in intellectual risk-taking for their development by communicating clinical decision-making processes even at the risk of being wrong, openly addressing errors and gaps, and intentionally seeking out uncomfortable experiences. Intentional curation of a learning network is the deliberate development of a consortium of trusted individuals who serve as mentors and sounding boards. We also identified a fourth theme related to the expression of learner behaviors: learning environment modulates behaviors. Active promotion of psychological safety is necessary for learners to express these behaviors. This safety is mediated through trusting relationships and expert supervisors who serve as colearners and role models.

Conclusions

We present several behaviors that allow identification of MALs among EM trainees. These data expand our understanding of MALs and the critical influence of the learning environment. Identification of these behaviors may allow for more precise categorization of targeted curricular interventions and meaningful learning outcomes.

Supportive and collaborative interdependence: Distinguishing residents' contributions within health care teams

INTRODUCTION

Individual assessments disregard team contributions, while team assessments disregard an individual's contributions. Interdependence has been put forth as a conceptual bridge between our educational traditions of assessing individual performance and our imminent challenge of assessing team-based performance without losing sight of the individual. The purpose of this study was to develop a more refined conceptualisation of interdependence to inform the creation of measures that can assess the interdependence of residents within health care teams.

METHODS

Following a constructivist grounded theory approach, we conducted 49 semi-structured interviews with various members of health care teams (e.g. physicians, nurses, pharmacists, social workers and patients) across two different clinical specialties-Emergency Medicine and Paediatrics-at two separate sites. Data collection and analysis occurred iteratively. Constant comparative inductive analysis was used, and coding consisted of three stages: initial, focused and theoretical.

RESULTS

We asked participants to reflect upon interdependence and describe how it exists in their clinical setting. All participants acknowledged the existence of interdependence, but they did not view it as part of a linear spectrum where interdependence becomes independence. Our analysis refined the conceptualisation of interdependence to include two types: supportive and collaborative. Supportive interdependence occurs within health care teams when one member demonstrates insufficient expertise to perform within their scope of practice. Collaborative interdependence, on the other hand, was not triggered by lack of experience/expertise within an individual's scope of practice, but rather recognition that patient care requires contributions from other team members.

CONCLUSION

In order to assess a team's collective performance without losing sight of the individual, we need to capture interdependent performances and characterise the nature of such interdependence. Moving away from a linear trajectory where independence is seen as the end goal can also help support efforts to measure an individual's competence as an interdependent member of a health care team.

A scoping review of self-monitoring in graduate medical education

BACKGROUND

Physicians and physicians-in-training have repeatedly demonstrated poor accuracy of global self-assessments, which are assessments removed from the context of a specific task, regardless of any intervention. Self-monitoring, an in-the-moment self-awareness of one's performance, offers a promising alternative to global self-assessment. The purpose of this scoping review is to better understand the state of self-monitoring in graduate medical education.

METHODS

We performed a scoping review following Arksey and O'Malley's six steps: identifying a research question, identifying relevant studies, selecting included studies, charting the data, collating and summarising the results and consulting experts. Our search queried Ovid Medline, Web of Science, PsychINFO, Eric and EMBASE databases from 1 January 1999 to 12 October 2022.

RESULTS

The literature search yielded 5363 unique articles. The authors identified 77 articles for inclusion. The search process helped create a framework to identify self-monitoring based on time and context dependence. More than 20 different terms were used to describe self-monitoring, and only 13 studies (17%) provided a definition for the equivalent term. Most research focused on post-performance self-judgements of a procedural skill (n = 31, 42%). Regardless of task, studies focused on self-judgement (n = 66, 86%) and measured the accuracy or impact on performance of self-monitoring (n = 41, 71%). Most self-monitoring was conducted post-task (n = 65, 84%).

CONCLUSION

Self-monitoring is a time- and context-dependent phenomenon that seems promising as a research focus to improve clinical performance of trainees in graduate medical education and beyond. The landscape of current literature on self-monitoring is sparse and heterogeneous, suffering from a lack of theoretical underpinning, inconsistent terminology and insufficiently clear definitions.

Fostering Adaptive Expertise Through Simulation

Technology-enhanced simulation has been used to tackle myriad challenges within health professions education. Recently, work has typically adopted a mastery learning orientation that emphasizes trainees' sequential mastery of increasingly complex material. Doing so has privileged a focus on performance and task completion, as captured by trainees' observable behaviors and actions. Designing simulation in these ways has provided important advances to education, clinical care, and patient safety, yet also placed constraints around how simulation-based activities were enacted and learning outcomes were measured. In tracing the contemporary manifestations of simulation in health professions education, this article highlights several unintended consequences of this performance orientation and draws from principles of adaptive expertise to suggest new directions. Instructional approaches grounded in adaptive expertise in other contexts suggest that uncertainty, struggle, invention, and even failure help learners to develop deeper conceptual understanding and learn innovative approaches to novel problems. Adaptive expertise provides a new lens for simulation designers to think intentionally around how idiosyncrasy, individuality, and inventiveness could be enacted as central design principles, providing learners with opportunities to practice and receive feedback around the kinds of complex problems they are likely to encounter in practice. Fostering the growth of adaptive expertise through simulation will require a fundamental reimagining of the design of simulation scenarios, embracing the power of uncertainty and ill-defined problem spaces, and focusing on the structure and pedagogical stance of debriefing. Such an approach may reveal untapped potential within health care simulation.

Navigating Challenging Conversations: The Interplay Between Inquiry and Knowledge Drives Preparation for Future Learning

Introduction

While some physicians hone their skills through informal learning in clinical practice, others do not. There is a lack of understanding of why some physicians seek improvement and how they use the workplace context to build their capabilities. Because physicians rarely pursue formal professional development activities to improve communication skills, examining physician-patient communication offers a powerful opportunity to illuminate important aspects of preparation for future learning in the workplace.

Methods

This qualitative observational study involved over 100 hours of observation of eight pediatric rehabilitation physicians as they interacted with patients and families at an academic teaching hospital in 2018-2020. Detailed field notes of observations, post-observation interviews, and exit interviews were the data sources. Data collection and analysis using a constructivist grounded theory approach occurred iteratively, and themes were identified through constant comparative analysis.

Results

Through their daily work, experienced physicians employ 'habits of inquiry' by constantly seeking a better understanding of how to navigate challenging conversations in practice through monitoring and attuning to situational and contextual cues, taking risks and navigating uncertainty while exploring new and varied ways of practicing, and seeking why their strategies are successful or not.

Discussion

Engaging in communication challenges drives physician learning through an interplay between habits of inquiry and knowledge: inquiry into how to improve their communication supported by existing conceptual knowledge to generate new strategies. These 'habits of inquiry' prompt continual reinvestment in problem solving to refine existing knowledge and to build new skills for navigating communication challenges in practice.

Trainees' perceptions of being allowed to fail in clinical training: A sense-making model

INTRODUCTION

Clinical supervisors allow trainees to fail during clinical situations when trainee learning outweighs concerns for patient safety. Trainees perceive failure as both educationally valuable and emotionally draining; however, the nuance of supervised failures has not been researched from the trainee perspective. This study explored trainees' awareness and their experience of failure and allowed failure to understand those events in-depth.

METHODS

We interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. Participants were a purposive sample, representing 1-10 years of clinical training in various specialties. Consistent with constructivist grounded theory, data collection and analysis were iterative, supporting theoretical sampling to explore themes.

RESULTS

Trainees reported that failure was a common, valuable, and emotional experience. They perceived that supervisors allowed failure, but they reported never having it explicitly confirmed or discussed. Therefore, trainees tried to make sense of these events on their own. If they interpreted a failure as allowed by the supervisor, trainees sought to ascertain supervisory intentions. They described situations where they judged supervisor's intentions to be constructive or destructive.

DISCUSSION

Our results confirm that trainees perceive their failures as valuable learning opportunities. In the absence of explicit conversations with supervisors, trainees tried to make sense of failures themselves. When trainees judge that they have been allowed to fail, their interpretation of the event is coloured by their attribution of supervisor intentions. Perceived intentions might impact the educational benefit of the experience. In order to support trainees' sense-making, we suggest that supervisory conversations during and after failure events should use more explicit language to discuss failures and explain supervisory intentions.

The Case for Feedback-in-Practice as a Topic of Educational Scholarship

The importance of clinical performance feedback is well established and the factors relevant to its effectiveness widely recognized, yet feedback continues to play out in problematic ways. For example, learning culture modifications shown to facilitate feedback have not seen widespread adoption, and the learner-educator interactions prescribed by research rarely occur organically. Nevertheless, medical learners achieve clinical competence, suggesting a need to expand educational scholarship on this topic to better account for learner growth. This Scholarly Perspective argues for a more extensive exploration of feedback as an educational activity embedded in clinical practice , where joint clinical work that involves an educator and learner provides a locus for feedback in the midst of performance. In these clinically embedded feedback episodes, learning and performance goals are constrained by the task at hand, and the educator guides the learner in collaboratively identifying problematic elements, naming and reframing the source of challenge, and extrapolating implications for further action. In jointly conducting clinical tasks, educators and learners may frequently engage in feedback interactions that are both aligned with workplace realities and consistent with current theoretical understanding of what feedback is. However, feedback embedded in practice may be challenged by personal, social, and organizational factors that affect learners' participation in workplace activity. This Scholarly Perspective aims to provide a conceptual framework that helps educators and learners be more intentional about and fully participatory in this important educational activity. By topicalizing this feedback-in-practice and exploring its integration with the more commonly foregrounded feedback-on-practice , future educational scholarship may achieve optimal benefit to learners, educators, and clinical practice.

Pediatric Residency Training amid the COVID-19 Pandemic: Exploring the Impact of Supervision and Clinical Practice Guidelines on Clinical and Financial Outcomes

Objective

This study is aimed at calculating the magnitude of the effect of clinical practice guidelines (CPG) and supervision in inhibiting the negative impact of the COVID-19 pandemic on clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents in academic medical center (AMC) hospitals during the COVID-19 pandemic.

Methods

The cohort retrospective study was conducted. This study collected patient data from pediatric residency programs. A research cohort consisted of non-COVID-19 pediatric patients at Dr. Soetomo General Academic Hospital. This study compared the subgroup of patients treated during the pandemic with those treated before the pandemic. The results were analyzed using SPSS 26.0 and Smart-PLS.

Results

There was a 41.4% decrease in pediatric inpatients during the pandemic with an increased severity level and complexity level, a reduction of 7.46% availability of supervisors, an increase of 0.4% in readmission < 30 days, an increase of 0.31% in-hospital mortality, an increase the total costs of care, and a decrease of insurance claim profit. CPG did not moderate the effect of the COVID-19 pandemic on the clinical outcomes (β = -0.006, P = 0.083) but moderated the financial outcomes (β = -0.022, P = 0.000), by reducing the total cost of care and increasing insurance claim profit. Supervision moderated the effect of the COVID-19 pandemic on the clinical outcomes (β = 0.040, P = 0.000) by increasing aLOS and on the financial outcomes (β = -0.031, P = 0.000) by reducing the total cost of care and increasing insurance claim profit. This study model had a 24.0% variance of explanatory power for clinical outcomes and 49.0% for financial outcomes. This study's structural model effectively predicted clinical outcomes (Q 2 = 0.238) and financial outcomes (Q 2 = 0.413).

Conclusion

Direct supervision inhibited the negative impact of the COVID-19 pandemic on both clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents, while CPG only inhibited the negative impact on financial outcomes. Implication of This Study. In a disaster, the availability of CPG and direct supervision makes AMC hospitals able to inhibit the negative impact of disasters on clinical and financial outcomes.

Exploring factors influencing coping with uncertainties in medical practice: insights from residents' experience

PURPOSE

Despite attempts to teach medical students and trainees about uncertainty in medical practice and how to tolerate it, studies on how to promote tolerance to uncertainty remain scarce. this study aims to investigate factors that could foster residents' tolerance to uncertainty.

METHODS

The authors used data sources, including semi-structured individual in-depth interviews with 20 medical residents working in two tertiary university hospitals. Inductive analysis of interview records determined key themes, identified categories, and performed a theoretical-type analysis of the participants' coping behaviors according to the attributes of uncertainty tolerance.

RESULTS

Two characteristics of residents which could lead to constructive coping with uncertainty were discovered: (1) communicative/collaborative behavior with their colleagues, superiors, and patients and (2) self-reflective/self-directed attitude in their medical practice. Both were used to classify four types of uncertainty coping behaviors: adaptive, self-contained, submissive, and isolated.

CONCLUSION

Fostering communicative/collaborative behaviors and self-reflective/self-directed attitude throughout the training period may result in residents being more tolerant of uncertainties in medical practice.

Approaching Training-Practice Gaps After the Transition: A Practice Proposal for Supervision After Training

Transitions within medical, veterinarian, and other health professional training, from classroom to workplace, between undergraduate, postgraduate, fellowship phases, and to unsupervised clinical practice, are often stressful. Endeavors to alleviate inadequate connections between phases have typically focused on preparation of learners for a next phase. Yet, while some of these efforts show results, they cannot obliviate transitional gaps. If reformulated as ‘not completely ready to assume the expected responsibilities in the next phase’, transitions may reflect intrinsic problems in a training trajectory. Indeed, the nature of classroom teaching and even skills training for example, will never fully reflect the true context of clinical training. In various stages of clinical training, the supervision provided to trainees, particularly medical residents, has increased over the past decades. This addresses calls for enhanced patient safety, but may inadequately prepare trainees for unsupervised practice. Transitions often evolve around the question how much support or supervision incoming trainees or junior professionals require. We propose to consider receiving incoming trainees and new employees in clinical workplaces with a conversation about required supervision for discrete tasks, or entrustable professional activities (EPAs). EPAs lend themselves for the question: “At what level of supervision will you be able to carry out this task?”. This question can be answered by both the trainee or junior employee and the supervisor or employer and can lead to agreement about specified supervision for a defined period of time. We expect that this “supported autonomy tool” could alleviate stress and enhance continued development after transitions.

Beyond competence: Towards a more holistic perspective in medical education

The authors draw connections between four State of the Science articles that encourage diversity in our field while worrying about heterogeneity of terminology impeding theory integration and practical impact.

Disruption and Dissonance: Exploring Constructive Tensions Within Research in Medical Education

The academic medicine community has experienced an unprecedented level of disruption in recent years. In this context, the authors consider how the disruptions have impacted the state of research in medical education (RIME). The articles in this year's RIME supplement reflect several constructive tensions that provide insight on future for the field. In this commentary, the authors discuss themes and propose a framework for the future. Recommendations include: normalizing help seeking during times of disruption and uncertainty, contextualizing the application of complex approaches to assessment, advancing and problematizing innovation, and recognizing the deeply embedded and systemic nature of inequities.