Chris Watling

Guidelines: the do's, don'ts and don't knows of feedback for clinical education

IntroductionThe guidelines offered in this paper aim to amalgamate the literature on formative feedback into practical Do’s, Don’ts and Don’t Knows for individual clinical supervisors and for the institutions that support clinical learning.MethodsThe authors built consensus by an iterative process. Do’s and Don’ts were proposed based on authors’ individual teaching experience and awareness of the literature, and the amalgamated set of guidelines were then refined by all authors and the evidence was summarized for each guideline. Don’t Knows were identified as being important questions to this international group of educators which if answered would change practice. The criteria for inclusion of evidence for these guidelines were not those of a systematic review, so indicators of strength of these recommendations were developed which combine the evidence with the authors’ consensus.ResultsA set of 32 Do and Don’t guidelines with the important Don’t Knows was compiled along with a summary of the evidence for each. These are divided into guidelines for the individual clinical supervisor giving feedback to their trainee (recommendations about both the process and the content of feedback) and guidelines for the learning culture (what elements of learning culture support the exchange of meaningful feedback, and what elements constrain it?)ConclusionFeedback is not easy to get right, but it is essential to learning in medicine, and there is a wealth of evidence supporting the Do’s and warning against the Don’ts. Further research into the critical Don’t Knows of feedback is required. A new definition is offered: Helpful feedback is a supportive conversation that clarifies the trainee’s awareness of their developing competencies, enhances their self-efficacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur.

Thresholds of Principle and Preference: Exploring Procedural Variation in Postgraduate Surgical Education.

Background Expert physicians develop their own ways of doing things. The influence of such practice variation in clinical learning is insufficiently understood. Our grounded theory study explored how residents make sense of, and behave in relation to, the procedural variations of faculty surgeons. Method We sampled senior postgraduate surgical residents to construct a theoretical framework for how residents make sense of procedural variations. Using a constructivist grounded theory approach, we used marginal participant observation in the operating room across 56 surgical cases (146 hours), field interviews (38), and formal interviews (6) to develop a theoretical framework for residents’ ways of dealing with procedural variations. Data analysis used constant comparison to iteratively refine the framework and data collection until theoretical saturation was reached. Results The core category of the constructed theory was called thresholds of principle and preference and it captured how faculty members position some procedural variations as negotiable and others not. The term thresholding was coined to describe residents’ daily experiences of spotting, mapping, and negotiating their faculty members’ thresholds and defending their own emerging thresholds. Conclusions Thresholds of principle and preference play a key role in workplace-based medical education. Postgraduate medical learners are occupied on a day-to-day level with thresholding and attempting to make sense of the procedural variations of faculty. Workplace-based teaching and assessment should include an understanding of the integral role of thresholding in shaping learners’ development. Future research should explore the nature and impact of thresholding in workplace-based learning beyond the surgical context.

“They Have to Adapt to Learn”: Surgeons’ Perspectives on the Role of Procedural Variation in Surgical Education

OBJECTIVEnClinical research increasingly acknowledges the existence of significant procedural variation in surgical practice. This study explored surgeons perspectives regarding the influence of intersurgeon procedural variation on the teaching and learning of surgical residents.nnnDESIGN AND SETTINGnThis qualitative study used a grounded theory-based analysis of observational and interview data. Observational data were collected in 3 tertiary care teaching hospitals in Ontario, Canada. Semistructured interviews explored potential procedural variations arising during the observations and prompts from an iteratively refined guide. Ongoing data analysis refined the theoretical framework and informed data collection strategies, as prescribed by the iterative nature of grounded theory research.nnnPARTICIPANTSnOur sample included 99 hours of observation across 45 cases with 14 surgeons. Semistructured, audio-recorded interviews (n = 14) occurred immediately following observational periods.nnnRESULTSnSurgeons endorsed the use of intersurgeon procedural variations to teach residents about adapting to the complexity of surgical practice and the norms of surgical culture. Surgeons suggested that residents efforts to identify thresholds of principle and preference are crucial to professional development. Principles that emerged from the study included the following: (1) knowing what comes next, (2) choosing the right plane, (3) handling tissue appropriately, (4) recognizing the abnormal, and (5) making safe progress. Surgeons suggested that learning to follow these principles while maintaining key aspects of surgical culture, like autonomy and individuality, are important social processes in surgical education.nnnCONCLUSIONSnAcknowledging intersurgeon variation has important implications for curriculum development and workplace-based assessment in surgical education. Adapting to intersurgeon procedural variations may foster versatility in surgical residents. However, the existence of procedural variations and their active use in surgeons teaching raises questions about the lack of attention to this form of complexity in current workplace-based assessment strategies. Failure to recognize the role of such variations may threaten the implementation of competency-based medical education in surgery.

Considerations in the use of reflective writing for student assessment: issues of reliability and validity

Reflective writing is a popular tool to support the growth of reflective capacity in undergraduate medical learners. Its popularity stems from research suggesting that reflective capacity may lead to improvements in skills such as empathy, communication, collaboration and professionalism. This has led to assumptions that reflective writing can also serve as a tool for student assessment. However, evidence to support the reliability and validity of reflective writing as a meaningful assessment strategy is lacking.

(Re)Grounding grounded theory: a close reading of theory in four schools

The debate over what counts as theory has dominated methodological conversations in grounded theory research for decades. Four of the schools of thought in that debate – Glaserian, Straussian, Charmazian, and Clarkeian – hold different assumptions about what theory is and how it is made. The first two schools understand theory as an abstraction that exactingly accounts for exceptions. The second two schools understand theory as a process of describing voices hidden from public view. While Glaserian and Straussian coding processes focus on coding exceptions, Charmazian and Clarkeian coding processes focus on building a story of the participants or social phenomenon. This article attempts to clarify the goals of the schools in an effort to overcome the debate about which kinds of research count as grounded theory and which do not.

Labelling of mental illness in a paediatric emergency department and its implications for stigma reduction education

IntroductionStigmatizing attitudes and behaviours towards patients with mental illness have negative consequences on their health. Despite research regarding educational and social contact-based interventions to reduce stigma, there are limitations to the success of these interventions for individuals with deeply held stigmatizing beliefs. Our study sought to better understand the process of implicit mental illness stigma in the setting of axa0paediatric emergency department to inform the design of future educational interventions.MethodsWe conducted axa0qualitative exploration of mental illness stigma with interviews including physician, nurse, service user, caregiver and administrative staff participants (nxa0= 24). We utilized the implicit association test as axa0discussion prompt to explore stigma outside of conscious awareness. We conducted our study utilizing constructivist grounded theory methodology, including purposeful theoretical sampling and constant comparative analysis.ResultsOur study found that the confluence of socio-cultural, cognitive and emotional forces results in labelling of patients with mental illness as time-consuming, unpredictable and/or unfixable. These labels lead to unintentional avoidance behaviours from staff which are perceived as prejudicial and discriminatory by patients and caregivers. Participants emphasized education as the most useful intervention to reduce stigma, suggesting that educational interventions should focus on patient-provider relationships to foster humanizing labels for individuals with mental illness and by promoting provider empathy and engagement.DiscussionOur results suggest that educational interventions that target negative attributions, consider socio-cultural contexts and facilitate positive emotions in healthcare providers may be useful. Our findings may inform further research and interventions to reduce stereotypes towards marginalized groups in healthcare settings.

Use of empathy in psychiatric practice: constructivist grounded theory study

Background Psychiatry has faced significant criticism for overreliance on the Diagnostic and Statistical Manual of Mental Disorders (DSM) and medications with purported disregard for empathetic, humanistic interventions. Aims To develop an empirically based qualitative theory explaining how psychiatrists use empathy in day-to-day practice, to inform practice and teaching approaches. Method This study used constructivist grounded theory methodology to ask (a) ‘How do psychiatrists understand and use empathetic engagement in the day-to-day practice of psychiatry?’ and (b) ‘How do psychiatrists learn and teach the skills of empathetic engagement?’ The authors interviewed 17 academic psychiatrists and 4 residents and developed a theory by iterative coding of the collected data. Results This constructivist grounded theory of empathetic engagement in psychiatric practice considered three major elements: relational empathy, transactional empathy and instrumental empathy. As one moves from relational empathy through transactional empathy to instrumental empathy, the actions of the psychiatrist become more deliberate and interventional. Conclusions Participants were described by empathy-based interventions which are presented in a theory of ’empathetic engagement’. This is in contrast to a paradigm that sees psychiatry as purely based on neurobiological interventions, with psychotherapy and interpersonal interventions as completely separate activities from day-to-day psychiatric practice. Declaration of interest None. Copyright and usage

It's a Story, Not a Study: Writing an Effective Research Paper.

References: 1. Bordage G. Reasons reviewers reject and accept manuscripts. Acad Med. 2001;76:889–896. 2. Lingard L, Driessen E. How to tell compelling scientific stories. In: Cleland J, Durning SJ, eds. Researching Medical Education. Hoboken, NJ: Wiley-Blackwell; 2015. 3. @WriteforResearch, Twitter. 4. Lingard L. Joining a conversation: The problem/gap/hook heuristic. Perspect Med Educ. 2015;4:252–253. 5. Sword, H. Stylish Academic Writing. Cambridge, MA: Harvard; 2012. 6. Chan AW. Bias, spin, and misreporting: Time for full access to trial protocols and results. PLoS Med. 2008;5:e230. Author contact: lorelei.lingard@schulich.uwo.ca; Twitter: @LingardLorelei What’s the difference between study and story? First, the difference is structural: • A study lives in the methods and results of a report. • A story unfolds in the introduction and discussion/conclusion. Second, the difference is rhetorical: • The study must be reported accurately. • The story must be told persuasively. A good story is understandable, compelling, and memorable. It needs a good study at its core, but it uses that study as a launching point to contribute to a conversation in the world about a shared problem.

“Staying in the Game”: How Procedural Variation Shapes Competence Judgments in Surgical Education

Purpose Emerging research explores the educational implications of practice and procedural variation between faculty members. The potential effect of these variations on how surgeons make competence judgments about residents has not yet been thoroughly theorized. The authors explored how thresholds of principle and preference shaped surgeons’ intraoperative judgments of resident competence. Method This grounded theory study included reanalysis of data on the educational role of procedural variations and additional sampling to attend to their impact on assessment. Reanalyzed data included 245 hours of observation across 101 surgical cases performed by 29 participants (17 surgeons, 12 residents), 39 semistructured interviews (33 with surgeons, 6 with residents), and 33 field interviews with residents. The new data collected to explore emerging findings related to assessment included two semistructured interviews and nine focused field interviews with residents. Data analysis used constant comparison to refine the framework and data collection process until theoretical saturation was reached. Results The core category of the study, called staying in the game, describes how surgeons make moment-to-moment judgments to allow residents to retain their role as operators. Surgeons emphasized the role of principles in making these decisions, while residents suggested that working with surgeons’ preferences also played an important role in such intraoperative assessment. Conclusions These findings suggest that surgeons’ and residents’ work with thresholds of principle and preference have significant implications for competence judgments. Making use of these judgments by turning to situated assessment may help account for the subjectivity in assessment fostered by faculty variations.

On the value of the ‘subjective’ in studies of human behavior and cognition

Letter in response to: What people say ≠ what people do n nWe write this letter as a response to the letter ‘What people say ≠ what people do’, in which Dr. van Merrienboer acknowledges the generic value of subjective data but argues that they are unreliable, misleading, and best combined with objective data in the study of behaviour and cognitive processes [1]. As a research group studying teaching and learning in naturalistic clinical settings, we would like to offer a rejoinder. n nFirst, we question the dichotomous characterization of data as either subjective or objective. We argue that a spectrum, rather than a dichotomy, exists between ‘subjectivity’ and ‘objectivity’ in research data. At one end of the spectrum are the research approaches Van Merrienboer refers to that ‘[ask] people their opinions’ using interviews, while at the other end are research approaches that attempt to purge all external human influence. Between these poles, degrees of ‘subjectivity’ and ‘objectivity’ exist. Van Merrienboer’s focus on interview techniques that seek opinions belies the richness and diversity of naturalistic data collection methods, which can employ photography, critical incident interview techniques and video-recording of human experiences. Such data are not straightforwardly ‘subjective’: they combine, often in nuanced ways, both more subjective (influenced by human interpretation) and more objective (unfiltered representation) dimensions. Furthermore, the most ‘objective’ research – such as eye tracking analyses or double-blind randomized controlled trials – has subjective dimensions: it is necessarily influenced by human interpretation, from the wording of the question asked, to the inclusion/exclusion criteria of the sampling and the selection of statistical tests [2]. n nSecond, we respectfully disagree with Van Merrienboer’s marginalization of ‘subjective data’ in the study of cognition and behaviour. Calls for studying cognition and behaviour outside of the laboratory [3, 4] suggest that naturalistic research generally, and interview techniques in particular [5, 6] can offer meaningful insights into cognition and behaviour. Furthermore, many techniques exist for enhancing the rigour and authenticity of interview data regarding human cognition and behaviour [5, 6]. Interviews may be framed around clinical case presentations to elicit valuable insights into how clinicians work, [7] as in a recent study exploring faculty supervisory practices [8]. The ‘guided walk’ technique enriches interviews with authentic contextual details, as in a recent study of the lived experience of medical students in remote rural communities [9]. And interview protocols that incorporate workplace observations and visual methods can elicit tacit aspects of expert practice [10, 11]. Importantly, these techniques do not reduce subjectivity in the interview. Rather, they enrich interview data with more perspectives, more interpretive resources, more glimpses of the human participants’ implicit and explicit understandings of their work processes. n nIn conclusion, we suggest putting aside the dichotomy between subjective and objective data. We advocate that medical education researchers draw from the full spectrum of approaches in the exploration of human cognition and behaviour. From our perspective, each methodology and the data it produces have something to contribute; none is intrinsically more valuable.