We propose that a supervisor's perceived responsibility for the ward underlies adjustments between 'hands-on' (i.e. personal ward responsibility) and 'hands-off' (i.e. shared ward responsibility) styles. Our approaches to clinical supervision model combines this responsibility tension with the tension between patient care and teaching to illustrate four supervisory approaches, each with unique priorities influencing entrustment. Given the fluidity in supervision, documenting changes in oversight strategies, rather than absolute levels of entrustment, may be more informative for assessment purposes. Research is needed to determine if there is sufficient association between the supervision provided, the entrustment decision made and the supervisor's trust in a trainee to use these as proxies in assessing a trainee's competence.
Researchers should consider autoethnography as an important methodology to help advance our understanding of the culture and practices of medical education.
Supervision in the outpatient context is increasingly in the form of single day interactions between students and preceptors. This creates difficulties for effective feedback, which often depends on a strong relationship of trust between preceptor and student. Building on feedback theories focusing on the relational and dialogic aspects of feedback, this study explored the use of goal-oriented feedback in brief encounters with learners. This study used autoethnography to explore one preceptor's feedback interactions over an eight-month period both in the ambulatory setting and on the wards. Data included written narrative reflections on feedback interactions with twenty-three learners informed by discussions with colleagues and repeated reading of feedback literature. Thematic and narrative analyses of data were performed iteratively. Data analysis emphasized four recurrent themes. (1) Goal discussions were most effective when initiated early and integrated throughout the learning experience. (2) Both learner and preceptor goals were multiple and varied, and feedback needed to reflect this complexity. (3) Negotiation or co-construction of goals was important when considering the focus of feedback discussions in order to create safer, more effective interactions. (4) Goal oriented interactions offer potential benefits to the learner and preceptor. Goal oriented feedback promotes dialogue as it requires both preceptor and learner to acknowledge and negotiate learning goals throughout their interaction. In doing so, feedback becomes an explicit component of the preceptor-learner relationship. This enhances feedback interactions even in relatively brief encounters, and may begin an early educational alliance that can be elaborated with longer interactions.
Background
Longitudinal coaching in residency programmes is becoming commonplace and requires iterative and collaborative discussions between coach and resident, with the shared development of goals. However, little is known about how goal development unfolds within coaching conversations over time and the effects these conversations have. We therefore built on current coaching theory by analysing goal development dialogues within resident and faculty coaching relationships.
Methods
This was a qualitative study using interpretive description methodology. Eight internal medicine coach–resident dyads consented to audiotaping coaching meetings over a 1‐year period. Transcripts from meetings and individual exit interviews were analysed thematically using goal co‐construction as a sensitising concept.
Results
Two themes were developed: (i) The content of goals discussed in coaching meetings focused on how to be a resident, with little discussion around challenges in direct patient care, and (ii) co‐construction mainly occurred in how to meet goals, rather than in prioritising goals or co‐constructing new goals.
Conclusions
In analysing goal development in the coach–resident relationships, conversations focused mainly around how to manage as a resident rather than how to improve direct patient care. This may be because academic coaching provides space separate from clinical work to focus on the stage‐specific professional identity development of a resident. Going forward, focus should be on how to optimise longitudinal coaching conversations to ensure co‐regulation and reflection on both clinical competencies and professional identity formation.
Context
Transitions, although often difficult, represent integral components of medical training. New postgraduate trainees (first‐year residents) find themselves in an especially challenging transition as they are expected to fulfil both learning and service expectations concurrently. Workplace learning theory has been suggested as a lens through which to understand this unique educational, yet service‐oriented, role. This tension may be further amplified overnight when residents are on‐call with little to no support.
Objectives
The aims of this study were to explore the transition from medical student to resident with respect to the on‐call experience, and to provide theory‐based suggestions to enhance learning during this unique transition.
Methods
We conducted an interpretivist qualitative study by interviewing eight medical students and 10 first‐year residents from six different specialty training programmes across four academic sites. Each semi‐structured interview was transcribed verbatim and anonymised. Resident interview transcripts were initially coded for major themes, after which medical student interview transcripts were coded for consistencies and discrepancies.
Results
Four interrelated themes were identified in students’ and residents’ descriptions of on‐call experiences: (i) shift in responsibility; (ii) supervisory support; (iii) contextual conditions, and (iv) clarity of expectations. Generally, students were not able to anticipate the challenges they would face as residents on‐call, and residents perceived the transition as sudden with little emphasis placed on learning.
Conclusions
First‐year residents face multiple challenges during on‐call, which may prevent optimal learning in this setting. These challenges are amplified by the large gap between the respective roles of medical students and residents. We identified promoters of and barriers to effective learning in this environment and, by using workplace learning theory, provide recommendations for how we might be able to enhance medical students’ preparation for and first‐year residents’ learning during experiences of being on‐call.
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