Learning from the Experts: Stimulating Student Engagement in Small-group Active Learning

Introduction

Engaging students in small-group active learning methods is essential for their development. Yet, medical teachers frequently face difficulties in stimulating this engagement, resulting in students remaining passive or detached from the learning process. The aim of this study was to uncover ways in which expert medical teachers, proficient at cultivating high levels of student engagement, stimulate such engagement. This knowledge might inform faculty development initiatives, so that medical teachers can be better equipped to teach in a way that engages students.

Methods

We conducted an interview study using a constructivist grounded theory approach, integrating elements from appreciative inquiry. The eleven participants were qualified medical teachers who repeatedly received high scores on student engagement. Each interview was transcribed, coded, and analyzed using constant comparison until theoretical saturation was achieved.

Results

We constructed a grounded theory of expert teaching practice, describing student engagement as an integrated process consisting of three components: 1) aiming for a supportive learning environment; 2) employing a personal educational approach; and 3) facilitating the active learning process.

Discussion

This study uncovered that there are multiple ways to stimulate high levels of student engagement. Although there was consensus on the importance of a supportive learning environment and the ability to facilitate the active learning process, participants recognized the contextual nature of student engagement and took on a reflective mindset to adapt strategies to their specific situations. These findings highlight the need for faculty development initiatives to adopt a comprehensive, context-sensitive approach that considers the complexity of student engagement.

'Oh yes, that is also reflection'-Using discursive psychology to describe how GP registrars construct reflection

INTRODUCTION

Learners in medical education generally perceive that reflection is important, but they also find that reflection is not always valuable or practically applicable. We address the gap between the potential benefits of reflection and its practical implementation in medical education. We examined the perspective of Dutch GP registrars who (must) reflect for their GP specialty training to understand their participant perspective on reflection. Our aim is stimulating alignment between reflective activities that occur in a medical curriculum and the ideals of reflection as a valuable educational activity.

METHODS

We conducted, video-recorded and transcribed seven focus group sessions with GP registrars in 2021 across two Dutch GP educational programmes. We used discursive psychology to analyse the focus group data by focusing on 'assessments of reflection'. We analysed their discursive features (how something was said) and content features (what was said) and related these to each other to understand how GP registrars construct reflection.

RESULTS

Participants constructed reflection with nuance; they combined negative and positive assessments that displayed varied orientations to reflection. First, their combined assessments showed complex orientations to norms and experiences with reflecting in practice and that these are not simply negative or positive. Second, GP registrars constructed reflection as a negotiable topic and showed how reflection and its value can be variably understood. Third, through combined assessments, they displayed an orientation to the integration of reflection with other educational tasks, which impacts its value.

CONCLUSIONS

Generally, GP registrars speak positively about reflection, but the value of reflection partly depends on its proper integration with other educational tasks. When meaningful integration fails, activities to stimulate reflection can overshoot their own goal and hamper learner motivation to reflect. Developing a healthy 'reflection culture' could mitigate some challenges. Therein, reflection is treated as important while learners also have adequate autonomy.

How to Grow a Professional Identity: Philosophical Gardening in the Field of Medical Education

In this philosophical reflection, we - following the philosopher Heidegger - introduce two farmers who represent different ways in which one can develop growth (see https://www.youtube.com/watch?v=g7jZigyfKHI for instructional video). One is a traditional farmer who entrusts the seeds to the soil and cultivates them with care and trust. The other is a modern farmer who takes an industrialized approach and positions the seeds and 'challenges-forth' the crops to show themselves in a certain way. We use these farmers as an analogy for the ways in which we as medical educators can and should relate to those we 'care' for: medical students and trainees. Taking a philosophical stance, and accounting for our own positionality and involvement in the analysis, we focus on 'Professional Identity Formation' and its operationalization in the field of medical education. We identify three main approaches medical education has taken to identity: as an individual trait, as a set of behaviors, and as a socialization process. All these approaches have at their root a similar assumption, namely that all inner processes can be made visible. We challenge this representational paradigm and use 'philosophical gardening' to raise awareness of what can and cannot be measured and controlled. Finally, we suggest educational approaches that leave space for diversity in students' experiences, learning approaches, and growth. We share good practices of brave teachers and curriculum designers whose interventions are characterized by less control and fewer measurements of personal growth, but more trust and free spaces for authentic learning.

Twelve tips for patient involvement in health professions education

Moving towards person-centered care, with equal partnership between healthcare professionals and patients, requires a solid role for the patient in the education of students and professionals. Patients can be involved as teachers, assessors, curriculum developers, and policy-makers. Yet, many of the initiatives with patients are isolated, small events for targeted groups and there is a lack of patient involvement at the institutional level. To support educators in involving patients, both at the institutional level and at single educational encounters, we offer twelve practical tips. This paper came about through an innovative collaboration between healthcare professionals, educators, teachers, and patients. These tips can be used as a tool to start or reinforce patient involvement in health professions education and provide guidance on how to make it a sustainable part of the curriculum. The article involves organizational conditions for success, tips for sustainable partnerships, ideas for curriculum design and proposes concrete teaching strategies. Finally, besides practical tips, we stress that involving patients in education is not business as usual, and paradoxically this needs to be acknowledged before it can become business as usual.

Autonomy-supportive decision-making in maternity care during prenatal consultations: a qualitative interaction analysis

OBJECTIVES

The aim of this study was to identify mechanisms of autonomy-supportive consultation (ASC) that maternity care professionals use during decision-making in prenatal consultations.

DESIGN

This study was a descriptive, qualitative analysis of professional-patient interactions in maternity care, using concepts and analytic procedures of conversation analysis.

SETTING

The prenatal consultations took place in hospitals and midwifery practices in the Netherlands. This study was part of a larger project. For the current study, we selected prenatal consultations concerning three topics in which patients make their own choices.

PARTICIPANTS

The first author invited the patient who was waiting in the waiting room. Participants were not selected a priori.

MAIN OUTCOME MEASURES

The main outcome measures were mechanisms of ASC.

RESULTS

We selected 20 consultations which were conducted by 20 different professionals. We found eight mechanisms in the professional-patient interaction which were categorised into three overarching themes. The first theme, 'Lightheartedness', comprises the interactional mechanisms 'minimising language' and 'humour'. The theme 'Orientation to agreement' describes how professionals and patients seem to be oriented towards demonstrating agreement and mutual understanding. The last theme, 'Offering information and options', describes the professional formally giving factual information almost completely without verbal interaction between the professional and the patient.

CONCLUSION

The results of this study show that the model of ASC can be enriched by adding minimising language and humour to the mechanisms that can be used to fulfil the psychological need 'relatedness'. Second, our results show that professionals use only few mechanisms to meet the patients' psychological needs 'competence' and 'autonomy'. They mainly use information giving to meet patients' need competence. To meet patients' need for autonomy, the professionals keep all options open. This suggests that professionals could pay more attention to other mechanisms to meet patients' needs for 'competence' and 'autonomy'.

Turkish imams and their role in decision-making in palliative care: A Directed Content and Narrative analysis

BACKGROUND

Muslims are the largest religious minority in Europe. When confronted with life-threatening illness, they turn to their local imams for religious guidance.

AIM

To gain knowledge about how imams shape their roles in decision-making in palliative care.

DESIGN

Direct Content Analysis through a typology of imam roles. To explore motives, this was complemented by Narrative Analysis.

SETTING/PARTICIPANTS

Ten Turkish imams working in the Netherlands, with experience in guiding congregants in palliative care.

RESULTS

The roles of Jurist, Exegete, Missionary, Advisor and Ritual Guide were identified. Three narratives emerged: Hope can work miracles, Responsibility needs to be shared, and Mask your grief. Participants urged patients not to consent to withholding or terminating treatment but to search for a cure, since this might be rewarded with miraculous healing. When giving consent seemed unavoidable, the fear of being held responsible by God for wrongful death was often managed by requesting fatwa from committees of religious experts. Relatives were urged to hide their grief from dying patients so they would not lose hope in God.

CONCLUSION

Imams urge patients' relatives to show faith in God by seeking maximum treatment. This attitude is motivated by the fear that all Muslims involved will be held accountable by God for questioning His omnipotence to heal. Therefore, doctors may be urged to offer treatment that contradicts medical standards for good palliative care. To bridge this gap, tailor-made palliative care should be developed in collaboration with imams. Future research might include imams of other Muslim organizations.

Medical student engagement in small-group active learning: A stimulated recall study

BACKGROUND

Active learning relies on students' engagement with teachers, study materials and/or each other. Although medical education has adopted active learning as a core component of medical training, teachers have difficulties recognising when and why their students engage or disengage and how to teach in ways that optimise engagement. With a better understanding of the dynamics of student engagement in small-group active learning settings, teachers could be facilitated in effectively engaging their students.

METHODS

We conducted a video-stimulated recall study to explore medical students' engagement during small-group learning activities. We recorded one teaching session of two different groups and selected critical moments of apparent (dis)engagement. These moments served as prompts for the 15 individual semi-structured interviews we held. Interview data were analysed using Template Analysis style of thematic analysis. To guide the analysis, we used a framework that describes student engagement as a dynamic and multidimensional concept, consisting of behavioural, cognitive and emotional components.

RESULTS

The analysis uncovered three main findings: (1) In-class student engagement followed a spiral-like pattern. Once students were engaged or disengaged on one dimension, other dimensions were likely to follow suit. (2) Students' willingness to engage in class was decided before class, depending on their perception of a number of personal, social and educational antecedents of engagement. (3) Distinguishing engagement from disengagement appeared to be difficult for teachers, because the intention behind student behaviour was not always identifiable.

DISCUSSION

This study adds to the literature by illuminating the dynamic process of student engagement and explaining the difficulty of recognising and influencing this process in practice. Based on the importance of discerning the intentions behind student behaviour, we advise teachers to use their observations of student (dis)engagement to initiate interaction with students with open and inviting prompts. This can help teachers to (re-)engage students in their classrooms.

Do medical specialists cope with stressors through fulfillment of basic psychological needs of self-determination theory

OBJECTIVES

To explore factors influencing work motivation negatively and the role of the fulfillment of basic psychological needs, described by the self-determination theory of motivation, as a possible coping mechanism for medical specialists.

METHODS

A qualitative study was conducted in an academic medical center in the United States. Twelve medical specialists from different disciplines were recruited through convenience, snowball, and purposive sampling and shadowed for two days each. Semi-structured interviews were conducted afterwards. Data were transcribed, and thematic analysis was used for coding. Themes were finalized through discussion and consensus.

RESULTS

Medical specialists experience three main themes that are identified as stressors; 1) administrative tasks, so-called "administrative jungle", 2) delays and inefficiencies, and 3) poor patient outcomes. To be able to cope with these stressors, medical specialists construct different copingnarratives. Two coping narratives could be linked to autonomy: a narrative of acceptance and a narrative of reinstating autonomy. One coping narrative could be linked to relatedness: a narrative of relationships. No coping narrative could be linked to competence.

CONCLUSIONS

The results indicate that coping narratives about autonomy and relatedness are used to cope with moments of pressure, demand, or difficulty, so that patient care can continue to be the first priority. Becoming aware of these coping narratives, using them and reflecting on one's own can help medical specialists in successfully coping with stressors in their work lives. In turn, this can improve specialists wellbeing and performance for patient care as motivation remains.

12 tips to hear the voices of introverts in medical education … and to improve the learning climate for everyone

This article was migrated. The article was marked as recommended. Small group, highly interactive teaching is growing in popularity, making medical school stacked in favor of the extraverted student. The resulting discomfort experienced by introverted students is well documented and troubling. Not just for their wellbeing, but also for the educational climate as a whole. Everyone misses out on learning opportunities when a group of students is not heard or feels uncomfortable to speak up. In this piece, we offer twelve tips to create a safe and comfortable learning environment for all students, regardless of where they find themselves on the introvert-extravert continuum. In these tips we will focus on self-knowledge and perceptions of silence, didactic strategies and learning activities, starting a conversation to become more aware of differences and reflect on them, training for introverted students and fair assessment.

'One size does not fit all': The value of person-centred analysis in health professions education research

Health professions education (HPE) research is dominated by variable-centred analysis, which enables the exploration of relationships between different independent and dependent variables in a study. Although the results of such analysis are interesting, an effort to conduct a more person-centred analysis in HPE research can help us in generating a more nuanced interpretation of the data on the variables involved in teaching and learning. The added value of using person-centred analysis, next to variable-centred analysis, lies in what it can bring to the applications of the research findings in educational practice. Research findings of person-centred analysis can facilitate the development of more personalized learning or remediation pathways and customization of teaching and supervision efforts. Making the research findings more recognizable in practice can make it easier for teachers and supervisors to understand and deal with students. The aim of this article is to compare and contrast different methods that can be used for person-centred analysis and show the incremental value of such analysis in HPE research. We describe three methods for conducting person-centred analysis: cluster, latent class and Q‑sort analyses, along with their advantages and disadvantage with three concrete examples for each method from HPE research studies.

Learning about stress from building, drilling and flying: a scoping review on team performance and stress in non-medical fields

Background

Teamwork is essential in healthcare, but team performance tends to deteriorate in stressful situations. Further development of training and education for healthcare teams requires a more complete understanding of team performance in stressful situations. We wanted to learn from others, by looking beyond the field of medicine, aiming to learn about a) sources of stress, b) effects of stress on team performance and c) concepts on dealing with stress.

Methods

A scoping literature review was undertaken. The three largest interdisciplinary databases outside of healthcare, Scopus, Web of Science and PsycINFO, were searched for articles published in English between 2008 and 2020. Eligible articles focused on team performance in stressful situations with outcome measures at a team level. Studies were selected, and data were extracted and analysed by at least two researchers.

Results

In total, 15 articles were included in the review (4 non-comparative, 6 multi- or mixed methods, 5 experimental studies). Three sources of stress were identified: performance pressure, role pressure and time pressure. Potential effects of stress on the team were: a narrow focus on task execution, unclear responsibilities within the team and diminished understanding of the situation. Communication, shared knowledge and situational awareness were identified as potentially helpful team processes. Cross training was suggested as a promising intervention to develop a shared mental model within a team.

Conclusion

Stress can have a significant impact on team performance. Developing strategies to prevent and manage stress and its impact has the potential to significantly increase performance of teams in stressful situations. Further research into the development and use of team cognition in stress in healthcare teams is needed, in order to be able to integrate this ‘team brain’ in training and education with the specific goal of preparing professionals for team performance in stressful situations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00865-7.

Knowledge, skills and beetles: respecting the privacy of private experiences in medical education

In medical education, we assess knowledge, skills, and a third category usually called values or attitudes. While knowledge and skills can be assessed, this third category consists of 'beetles', after the philosopher Wittgenstein's beetle-in-a-box analogy. The analogy demonstrates that private experiences such as pain and hunger are inaccessible to the public, and that we cannot know whether we all experience them in the same way. In this paper, we claim that unlike knowledge and skills, private experiences of medical learners cannot be objectively measured, assessed, or directly accessed in any way. If we try to do this anyway, we risk reducing them to knowledge and skills-thereby making curriculum design choices based on what can be measured rather than what is valuable education, and rewarding zombie-like student behaviour rather than authentic development. We conclude that we should no longer use the model of representation to assess attitudes, emotions, empathy, and other beetles. This amounts to, first of all, shutting the door on objective assessment and investing in professional subjective assessment. Second, changing the way we define 'fuzzy concepts' in medical education, and stimulating conversations about ambiguous terms. Third, we should reframe the way we think of competences and realize only part of professional development lies within our control. Most importantly, we should stop attempting to measure the unmeasurable, as it might have negative consequences.

How to … do mixed-methods research

As a clinician, you will often combine patients' narratives with test results in order to obtain a coherent picture and then decide on a way forward. As an educator, you are also likely to combine different information from your learners to arrive at the best feedback, judgement or supervision plan. This is what researchers do when undertaking mixed-methods research: qualitative and quantitative data are typically brought together to provide different insights than could be achieved with a single type of data and analysis. Mixed-methods research has much to offer the clinical teacher but may involve more complex study designs than other types of research. Therefore, this article aims to highlight the different designs of mixed-methods research, and the opportunities and challenges that it provides, in order to support researchers who may be undertaking their first mixed-methods research study.

Organic or organised: an interaction analysis to identify how interactional practices influence participation in group decision meetings for residency selection

OBJECTIVES

This study aims to shed light on interactional practices in real-life selection decision-making meetings. Adequate residency selection is crucial, yet currently, we have little understanding of how the decision-making process takes place in practice. Since having a wide range of perspectives on candidates is assumed to enhance decision-making, our analytical focus will lie on the possibilities for committee members to participate by contributing their perspective.

DESIGN

We analysed interaction in seven recorded real-life selection group decision meetings, with explicit attention to participation.

SETTING

Selection meetings of four different highly competitive specialties in two Dutch regions.

PARTICIPANTS

54 participants discussed 68 candidates.

METHODS

To unravel interactional practices, group discussions were analysed using a hybrid data-driven, iterative analytical approach. We paid explicit attention to phenomena which have effects on participation. Word counts and an inductive qualitative analysis were used to identify existing variations in the current practices.

RESULTS

We found a wide variety of practices. We highlight two distinct interactional patterns, which are illustrative of a spectrum of turn-taking practices, interactional norms and conventions in the meetings. Typical for the first pattern-'organised'-is a chairperson who is in control of the topic and turn-taking process, silences between turns and a slow topic development. The second pattern-'organic'-can be recognised by overlapping speech, clearly voiced disagreements and negotiation about the organisation of the discussion. Both interactional patterns influence the availability of information, as they create different types of thresholds for participation.

CONCLUSIONS

By deconstructing group decision-making meetings concerning resident selection, we show how structure, interactional norms and conventions affect participation. We identified a spectrum ranging from organic to organised. Both ends have different effects on possibilities for committee members to participate. Awareness of this spectrum might help groups to optimise decision processes by enriching the range of perspectives shared.

How to … use qualitative research to change practice

The ‘How to …’ series focuses on how to do qualitative research. But how can qualitative research enhance patient care? This paper aims to support health care practitioners, educators and researchers who are interested in bridging the gap between research and practice (both clinical and educational), to guide improvements that can ultimately benefit patients. We present action research and The Change Laboratory method as two approaches that typically involve qualitative research and have potential to change practice, blending scientific inquiry with social action. These approaches establish close research–practice partnerships and help answer tricky ‘why’ and ‘how’ questions that may unlock deep insights to enhance learning and patient care.

Developing a two-dimensional model of unprofessional behaviour profiles in medical students

Standardized narratives or profiles can facilitate identification of poor professional behaviour of medical students. If unprofessional behaviour is identified, educators can help the student to improve their professional performance. In an earlier study, based on opinions of frontline teachers from one institution, the authors identified three profiles of medical students' unprofessional behaviour: (1) Poor reliability, (2) Poor reliability and poor insight, and (3) Poor reliability, poor insight and poor adaptability. The distinguishing variable was Capacity for self-reflection and adaptability. The current study used Nominal Group Technique and thematic analysis to refine these findings by synthesizing experts' opinions from different medical schools, aiming to develop a model of unprofessional behaviour profiles in medical students. Thirty-one experienced faculty, purposively sampled for knowledge and experience in teaching and evaluation of professionalism, participated in five meetings at five medical schools in the Netherlands. In each group, participants generated ideas, discussed them, and independently ranked these ideas by allocating points to them. Experts suggested ten different ideas, from which the top 3 received 60% of all ranking points: (1) Reflectiveness and adaptability are two distinct distinguishing variables (25%), (2) The term reliability is too narrow to describe unprofessional behaviour (22%), and (3) Profiles are dynamic over time (12%). Incorporating these ideas yielded a model consisting of four profiles of medical students' unprofessional behaviour (accidental behaviour, struggling behaviour, gaming-the-system behaviour and disavowing behaviour) and two distinguishing variables (reflectiveness and adaptability). The findings could advance educators' insight into students' unprofessional behaviour, and provide information for future research on professionalism remediation.

A Road Map for Attending to Medical Students' Professionalism Lapses

PURPOSE

To develop a road map for educators attending to medical students' professionalism lapses, aiming to offer an empirical base for approaching students who display such lapses.

METHOD

Between October 2016 and January 2018, 23 in-depth interviews with 19 expert faculty responsible for remediation from 13 U.S. medical schools were conducted about the way they handle students' professionalism lapses. Three researchers independently completed three rounds of coding. Data collection, coding, and analysis were performed in a constant comparative process. A constructivist grounded theory approach was used to develop an explanatory model for attending to students' professionalism lapses.

RESULTS

Based on participants' descriptions, the authors developed a three-phase approach for attending to professionalism lapses. In phase 1, experts enacted the role of concerned teacher, exploring the lapse from the student's perspective. In phase 2, they functioned as supportive coach, providing feedback on professionalism values, improving skills, creating reflectiveness, and offering support. In phase 3, if the student did not demonstrate reflectiveness and improvement, and especially if (future) patient care was potentially compromised, participants assumed an opposite role: gatekeeper of the profession.

CONCLUSIONS

An explanatory model for attending to professionalism lapses that fits in the overarching "communities of practice" framework was created. Whereas phase 1 and 2 aim at keeping students in the medical community, phase 3 aims at guiding students out. These findings provide empirical support to earlier descriptive, opinion-based models and may offer medical educators an empirical base for attending to students who display professionalism lapses.

The reflective zombie: Problematizing the conceptual framework of reflection in medical education

Reflection is an ambiguous and profoundly complex human activity. We celebrate the developments in teaching and researching reflection in education, yet have identified flaws in the way reflection has been operationalized: medical education has translated the age-old concept into a teachable and measureable construct. We fear that in this process of operationalization, the philosophical underpinnings of reflection have been discarded. We illustrate this with a thought experiment about a 'reflective zombie': students who have been conditioned to follow prescribed thought steps rather than engaging in truly reflective behaviour. In research and assessment of reflection, measuring tools might be unable to distinguish reflective zombies from students who authentically reflect. We argue that the instrumental approach lies at the root of this problem as it limits the rich concept of reflection and illustrate our point by describing problems related to paradigm (we are looking at reflection in the wrong way), methods (we are using the wrong tools), and epistemics (can we even know what we want to know?). We offer three suggestions for implementing reflection into the curriculum and for research into reflection. First, acknowledge the diversity of reflection and let go of the 'checklist approach'. Second, embrace the personal nature of reflection by stimulating awareness of one's personal reflection styles as part of the reflective process. Third, shift the focus of research to the practice of reflection. We believe that a strong vision on reflection can lead to a balanced curriculum, setting students up for a lifelong learning as a reflective practitioner.

How to…do research interviews in different ways

This article is the next instalment in our 'How to…' series about qualitative research, and focuses on interviews. In many ways, conducting research interviews can be compared with talking to a patient or a student, yet there are specific elements to consider if you want the interview data to be useful for a research study. In this article, we will reflect on what a 'good' research interview is. We will provide an overview of different types of interviews, both much used and more adventurous. Finally, we present a list of dilemmas and frequently asked questions, with tips, tricks and suggestions. This practical and concise article will be helpful when starting a qualitative research project using interviews. Getting access to participants' inner worlds is the real trick to acquiring rich data.

The swamplands of reflection: using conversation analysis to reveal the architecture of group reflection sessions

CONTEXT

Many medical schools include group reflection in their curriculum, and many researchers have considered both the concept and the outcomes of reflection. However, no research has been carried out on how 'reflective talk' is structured in the classroom. This paper describes how tutors and residents organise group reflection sessions in situ by describing an example of group reflection in medical education. Our aim is to provide an evidence base that can be used by medical educators to think about the way reflection should be included in their curriculum.

METHODS

We video-recorded 47 group reflection sessions of the general practice postgraduate training course at Erasmus University Medical School, Rotterdam. We used conversation analysis to unravel their overall structural organisation: the way participants organise and structure a conversation. Through micro-analysis of the moment-to-moment unfolding of group reflection, we distinguished the main building blocks that form the architecture of these sessions.

RESULTS

We found that participants consistently oriented towards the following activity types: significant event, reason for sharing, learning issue and learning uptake. There was variation in the order of the activity types, the amount of time spent on each of them, and how they were accomplished. By studying reflection in its messy social context, we found order, commonalities and patterns that were typical of the architecture of group reflection in this setting, even if no formal structure is prescribed.

CONCLUSIONS

In 'Exchange of Experience', the overall structural organisation consisted of activity types through which a case becomes shared, reflectable, learnable and valuable. There are essential discrepancies between cognitive reflection models and the reality of the classroom. Being conscious of this overall structural organisation can be a tool for tutors of these groups to help them navigate from one activity to another or to diagnose what is not working in the group discussion.

Collaborative Reflection Under the Microscope: Using Conversation Analysis to Study the Transition From Case Presentation to Discussion in GP Residents' Experience Sharing Sessions

PHENOMENON: In higher education, reflection sessions are often used when participants learn in the workplace. In the Netherlands, all General Practitioner training programs include regular meetings called Exchange of Experiences, in which General Practitioner trainees are expected to learn collaboratively from their own and one another's experiences. Despite this being common practice, we found little research into the structure and process of these sessions. The purpose of this study is to describe the structure and characteristics of group reflection by describing transitions in interactions. We aim to describe the tutor's role in some detail, as this could lead to faculty development.

APPROACH

In medical education, reflection is often approached from a cognitive perspective. However, learning in a group is also an interactional achievement. It is therefore relevant to study the sequential nature of group interaction in collaborative reflective practice. We have used conversation analysis to study the reflection meetings, zooming in on the transition between case presentation and discussion, focusing on the role of each of the participants in these transitions.

FINDINGS

The transitions were conversationally complex. Three interactional aspects recurred in the meetings. First, the transitions can be characterized as ambiguous, as there is ambiguity about what will happen next and the floor is open. Second, transitions are an arena for negotiations between case presenter, participants, and tutors, in which knowledge and the right to take the floor (epistemics) play an important part. Third, the tutor can have different interactional roles, namely, that of teacher, expert, facilitator, and active participant. The role of the tutor is important as the tutor's interactional behavior is part of the hidden curriculum. Insights: Conversation analysis focuses on the interaction in group learning and shows how the interaction is part of what is learned and how learning takes place. Transitions are the "messy" moments in interaction yet can tell a lot about the way in which group participants relate to one another. Being conscious of how the floor is taken, the tutor's roles, and the way negotiations take place could help medical educators in the way they shape collaborative learning sessions.

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

CONTEXT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The simulation game: an analysis of interactions between students and simulated patients

CONTEXT

Institutional interactions are often asymmetrical in that the professional has more control over the conversation. It is difficult to say who the professional is in simulated consultations between simulated patients (SPs) and medical students because these feature a real (educational) institutional context and a simulated (medical) institutional context. This study describes this asymmetry and makes educational recommendations based on the description.

METHODS

One hundred assessed conversations between SPs and Year 3 students were transcribed and analysed using discourse analysis (DA). We aimed to find linguistic patterns in predefined parts of the conversations (questions, topic initiations, openings, closings) that might suggest conversational dominance.

RESULTS

The SP is conversationally more dominant, despite performing the role of the patient, in that he or she asks more direct questions, is more likely to initiate topics, is more likely not to follow topic changes by students, and closes the consultation. The student is likely to follow topics initiated by the SP and to seek permission to pre-close the consultation.

CONCLUSIONS

The apparently greater dominance of the SP indicates that the simulated consultation differs from the doctor-patient consultation in certain key aspects. It is in that sense unrealistic. We argue, however, that 'realism' ought not to be a goal of simulated consultation and that what matters is that such consultations are sufficiently realistic for their educational purpose. We discuss the educational implications that follow from this.

Arts-based learning in medical education: the students' perspective

CONTEXT

Arts subjects are often included in medical school curricula to facilitate the exploration of non-scientific elements of medicine, such as communication, social, political, emotional and spiritual issues. However, little research has reported on students' experience of arts teaching. Performing Medicine is a programme created by the Clod Ensemble theatre company in collaboration with Barts and The London School of Medicine and Dentistry, and the Department of Drama at Queen Mary University, London. Professional artists run a range of workshops exploring issues relating to health care and work to develop students' professional skills in self-presentation, observation, communication, self-care and their understanding of difference. This article presents an analysis of student-written material about Performing Medicine.

METHODS

A dataset of written student materials (reflections and feedback), drawn from three academic years (2006-2009), was analysed using the qualitative methods of thematic analysis and word frequency analysis.

RESULTS

Five prevalent themes were identified: (i) Acting like a doctor; (ii) Developing broader awareness of others; (iii) The self in focus; (iv) The art of communication, and (v) A place for arts-based teaching within the medical curriculum. The corpus linguistic analysis confirmed and elaborated on the five themes found in the thematic analysis.

CONCLUSIONS

Students generally felt that arts teaching made a valuable contribution to the medical curriculum. Many felt the training would reduce 'performance anxiety' in situations such as examinations, presentations and new placements. Group work developed camaraderie and students enjoyed the opportunity to learn new skills through creative writing, theatre and movement sessions. Some sessions developed students' ability to engage with and relate to people from very different backgrounds than their own.

The reality of role-play: interruptions and amount of talk in simulated consultations

CONTEXT

The language and structure of doctor-patient consultations have been widely researched. Although simulated patients (SPs) are much used in communication skills teaching, the language of the simulated consultation has not received much attention.

OBJECTIVES

This study aimed to resolve the following questions. How are interruptions and numbers of words distributed in simulated consultations? Do they correlate with set variables (e.g. gender, scenario) or outcome variables (e.g. grade)?

METHODS

A total of 100 videotaped assessed consultations between SPs and Year 3 medical students were transcribed. Words by each participant were counted, and interruptions were coded and counted. Amount of talk and interruptions were chosen because they are potential markers of conversational dominance.

RESULTS

We found that SPs talk (55% versus 45% for students) and interrupt (74% versus 26% for students) significantly more than medical students. The scenario is significantly associated with the number of words and interruptions. Multivariable testing shows that female SPs are associated with more words. The number of words is significantly and positively associated with examination grade. The number of student interruptions is significantly and positively associated with grade.

CONCLUSIONS

Because the simulated consultation takes place in an institutional setting, the SP may have institutional power over the student. This may explain how findings from these role-play interactions differ from actual doctor-patient consultations. This suggests that simulated consultations are educational devices rather than exact representations of doctor-patient interactions. The authors hope this paper will contribute to a discussion about the nature of role-play in medical education.

Heartlift patients? An interview-based study of GP trainers and the impact of 'patients they like'

BACKGROUND

The concept of the 'heartsink patient' is well known and much used when talking about general practice. The opposite of this type of patient, however, has been little explored.

OBJECTIVE

To identify patient characteristics valued by GPs.

METHODS

Structured interview to collect narratives from GPs of individual patients, analysed qualitatively through thematic analysis and word frequency.

SETTING

Primary Care in Ireland.

PARTICIPANTS

GP trainers.

MAIN OUTCOME MEASURES

Emergent themes from four lead questions: Tell me about a patient you like, Tell me about the patient's personality, What have you learned about yourself as a GP?, What is different about being a GP as opposed to any other kind of doctor? In addition, a corpus linguistic analysis of word frequencies disclosed further themes, not identifiable on the surface of discourse.

RESULTS

Ten themes were identified: GPs valued patients who were likeable, a challenge, involved them in negotiation of the doctor-patient relationship, were interesting or virtuous and had a positive effect. GPs valued their profession in that they were facilitators, gave and elicited loyalty, formed personal attachments and had a different perspective.

CONCLUSIONS

'Heartlift patients' may be a robust concept, to counterbalance heartsink patients. Data collected are suitable for training, and could help GPs enhance a sense of vocation.