‘Sometimes the work just needs to be done’: socio-cultural influences on direct observation in medical training

Abstract

The cultural values of autonomy in learning and practice and efficiency in health care provision challenge the integration of direct observation into clinical training. Medical learners are often expected to ask for observation, but such requests are socially and culturally fraught, and likely to constrain the wider uptake of direct observation.

Assessment, feedback and the alchemy of learning

“…Direct observation is fundamental to both trustworthy assessment and credible feedback. Learners, however, maintain some ambivalence about direct observation during their clinical education: they recognise that it has value, but also identify a certain discomfort with being observed that shapes how they respond . For learners, being observed typically feels like being assessed .…”

Trust, entrustment decisions and a few things we shouldn’t forget

“…There is a wealth of research findings showing that exactly the culture (i. e. ‘the way we do things around here’) and contextual factors as described above may interfere with assessment quality. In medicine, for example, research findings clearly show that cultural values of autonomy in learning and practice, as well as aims to maximize efficiency in delivery of health care services, conflict with a culture that values direct observation or documentation of meaningful performance data [6, 12, 13]. In fact, cultural context may be the key factor determining trustworthiness of entrustment decisions.…”

Managing tensions in assessment: moving beyond either–or thinking

“…Clearly, health care and health care systems represent complex contexts, in which different organisational identities, goals, norms and values may drive tensions between learning and performance. Obviously, the tensions of competing goals in the delivery of high‐quality, efficient patient care, as well as high‐quality, efficient teaching and learning, are likely to become more salient under conditions of limited resources and increasing pressures for accountability . In health care settings, learning–performance tensions may surface if an individual is required to fulfil the multiple roles of learner as well as health care provider (trainees), or health care provider, coach and assessor (clinicians).…”