Lisa Faden

Attending Physician Variability: A Model of Four Supervisory Styles

Purpose There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities. Method Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review. Results Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees’ progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team. Conclusions The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.

Is medical education ready to embrace the socio-material?

Interprofessional Education. Defining IPE 2002. 2014. http:// caipe.org.uk/resources/definingipe/. [Accessed 16 March 2014] 3 Fenwick T, Nerland M, Jensen K. Sociomaterial approaches to conceptualising professional learning and practice. J Educ Work 2011;25 (1):1–13. 4 Mulcahy MD. Turning Around the Question of ‘Transfer’ in Education: tracing the sociomaterial. Educ Philos Theory 2013;45 (12):1276–89. 5 Fenwick T. Making to measure? Reconsidering assessment in professional continuing education. Stud Cont Educ 2009;31 (3): 229–44. 6 Moreau K, Cousins J. Program evaluation in family-centred paediatric rehabilitation settings: a review of evaluation studies and the potential use of participatory and collaborative evaluation approaches. Eval J Australasia 2011;11 (2):3–13. 7 Thistlethwaite J, Kumar K, Moran M, Saunders R, Carr S. An exploratory review of pre-qualification interprofessional education evaluations. J Interprof Care 2014;29:1–6. Early Online. 8 Reeves S, Boet S, Zierler B, Kitto S. Interprofessional Education and Practice Guide No. 3: evaluating interprofessional education. J Interprof Care 2015;29 (4):305–12. 9 Thistlethwaite J, Dickie R, Dallest K, Eley D. The development of work-based assessment (WBA) of teamwork instruments – an interprofessional approach. All Together Better Health VII; 6-8 June; Pittsburgh 2014. 10 Curran VR, Hollett A, Casimiro LM, Mccarthy P, Banfield V, Hall P, Lackie K, Oandasan I, Simmons B, Wagner S. Development and validation of the interprofessional collaborator assessment rubric (ICAR). J Interprof Care 2011;25: 339–44. 11 Belbin RM. Team roles at work, 2nd Edn. New York: Taylor & Francis 2012.

The Exposure Dilemma: Qualitative Study of Medical Student Opinions and Perceptions of Radiology

Purpose According to a national survey of over 900 Canadian medical students, the stereotype of an isolated radiologist working in a dark room persists. The purpose of this study is to use qualitative methods to explore the ways exposure to radiology in medical school impacts students’ opinions and perceptions of radiology and radiologists. Methods After receiving ethics approval, 4 focus groups were conducted, 1 per year of undergraduate medical training at Western University. The transcribed audio recordings and accompanying field notes, together with the open-ended questions obtained from the national survey, were analyzed using thematic analysis. Results Five hundred sixty students in medical school years 1 and 2 (preclerkship) participated in the national survey and 18 in the focus groups; 336 students in years 3 and 4 [clerkship] participated in the national survey and 10 in the focus groups. Three major findings emerged from the analysis of the data. First, stereotypes are perpetuated mainly through informal interactions. Second, there is limited exposure to radiology and radiologists in medical school, especially in preclerkship. Third, students want to know what to expect if they choose a career in radiology. Conclusions Medical students, especially those in preclerkship, are seeking accurate information to modify or reinforce radiology stereotypes. Limited exposure makes interactions with students impactful and mentorship essential. Students want meaningful interactions with radiologists and radiology residents.

Entrustment of the on-call senior medical resident role: implications for patient safety and collective care

BackgroundThe on-call responsibilities of a senior medicine resident (SMR) may include the admission transition of patient care on medical teaching teams (MTT), supervision of junior trainees, and ensuring patient safety. In many institutions, there is no standardised assessment of SMR competency prior to granting these on-call responsibilities in internal medicine. In order to fulfill competency based medical education requirements, training programs need to develop assessment approaches to make and defend such entrustment decisions.The purpose of this study is to understand the clinical activities and outcomes of the on-call SMR role and provide training programs with a rigorous model for entrustment decisions for this role.MethodsThis four phase study utilizes a constructivist grounded theory approach to collect and analyse the following data sets: case study, focus groups, literature synthesis of supervisory practices and return-of-findings focus groups.The study was conducted in two Academic Health Sciences Centres in Ontario, Canada. The case study included ten attending physicians, 13 SMRs, 19 first year residents and 14 medical students. The focus groups included 19 SMRs. The later, return-of-findings focus groups included ten SMRs.ResultsFive core on-call supervisory tasks (overseeing ongoing patient care, briefing, case review, documentation and preparing for handover) were identified, as well as a range of practices associated with these tasks. We also identified challenges that influenced the extent to which SMRs were able to effectively perform the core tasks. At times, these challenges led to omissions of the core tasks and potentially compromised patient safety and the admission transition of care.ConclusionBy identifying the core supervisory tasks and associated practices, we were able to identify the competencies for the on-call SMR role. Our findings can further be used by training programs for assessment and for making entrustment decisions.

History Teachers Imagining the Nation

A comparison of the enacted history curriculumi in Canada and the United States presents an opportunity to draw conclusions about the processes by which citizenship and the nation are constructed in the high school history classroom. While this collection has largely focused on how textbooks represent the nation, this chapter examines the teacher’s role in “enacting” or teaching the narrative content of textbooks. The interaction between history teachers and textbooks is largely unstudied (Thornton, 2006), yet teachers have the power to reinforce, challenge, or complicate the story of the nation as told in textbooks and other texts.

Advance care planning in community dwellers: A constructivist grounded theory study of values, preferences and conflicts:

Background: Most laypeople have not engaged in any advance care planning. Yet they are expected to articulate choices for life-sustaining interventions when they need admission to an acute care hospital in Canada. Aim: To describe how laypeople understand and make decisions for life-sustaining interventions when engaging in advance care planning. Design: Semi-structured interviews using constructivist grounded theory methodology and purposive sampling. Setting: Mid-size Canadian urban community Participants: In total, 20 healthy laypeople, 55 years and older, participated in in-depth semi-structured face-to-face interviews. Theoretical sampling was used to explore findings from the first round of interviews. Ten participants were invited for repeat interviews. Results: Four major themes were identified. Most participants claimed at the outset that they had engaged in advance care planning, but they were unfamiliar with contemporary life-sustaining interventions and had not factored these into their decisions. Participants’ confidence in their substitute decision makers precluded them from having explicit discussions with these individuals. Participants expressed their values and preferences in terms of unacceptable functional outcomes from serious illness, rather than desired interventions. The process of articulating their preferences within the interviews was subject to decision conflicts, which in turn helped them re-evaluate and refine their decisions. Conclusion: Advance care planning for the healthy older adult is challenging. Meaningful engagement may lead to conflicts in decision-making. Efforts to improve engagement must reflect what patients know and understand, their focus on unacceptable negative outcomes rather than interventions, and the need for iterative discussions with health-care providers.

Using a sociomaterial approach to generate new insights into the nature of interprofessional collaboration: Findings from an inpatient medicine teaching unit

ABSTRACT Today’s hospitals are burdened with patients who have complex health needs. This is readily apparent in an inpatient internal medicine setting. While important elements of effective interprofessional collaboration have been identified and trialled across clinical settings, their promise continues to be elusive. One reason may be that caring for patients requires understanding the size and complexity of healthcare networks. For example, the non-human ‘things’ that healthcare providers work with and take for granted in their professional practice—patient beds, diagnostic imaging, accreditation standards, work schedules, hospital policies, team rounds—also play a role in how care is shaped. To date, how the human and non-human act together to exclude, invite, and regulate particular enactments of interprofessional collaboration has been subject to limited scrutiny. Our paper addresses this gap by attending specifically to the sociomaterial. Drawing on empirical data collected from an Academic Health Sciences Centre’s inpatient medicine teaching unit setting in Ontario, Canada, we explore the influence of the sociomaterial on the achievement of progressive collaborative refinement, an ideal of how teams should work to support safe and effective patient care as patients move through the system. Foregrounding the sociomaterial, we were able to trace how assemblies of the human and the non-human are performed into existence to produce particular enactments of interprofessional collaboration that, in many instances, undermined the quality of care provided. Our research findings reveal the “messiness” of interprofessional collaboration, making visible how things presently assemble within the inpatient setting, albeit not always in the ways intended. These findings can be used to guide future innovation work in this and other similar settings.

Designing a Comprehensive Undergraduate Medical Education Radiology Curriculum Using the 5C's of Radiology Education Framework

The 5Cs of Radiology Education is a tool created from a recent qualitative study designed to explore how radiology exposures impact medical student opinions and perceptions of radiology and radiologists. It outlines the factors that the medical students identified as important for their radiology education. These factors are curriculum, coaching, collaborating, career, and commitment. The purpose of this paper is to provide a review of the literature of undergraduate medical education both broadly and more specifically to radiology education using the 5Cs of Radiology Education framework.

Recognising the importance of informal communication events in improving collaborative care

Background While the concept of collaboration is highly touted in the literature, most descriptions of effective collaboration highlight formal collaborative events; largely ignored are the informal collaborative events and none focusing on the frequent, ‘seemingly’ by chance communication events that arise and their role in supporting patient safety and quality care. Objective To identify the types of informal communication events that exist in the inpatient setting and better understand the barriers contributing to their necessity. Methods We undertook a constructivist grounded theory study in an inpatient internal medicine teaching unit in Ontario, Canada. Interview and observational data were collected across two phases; in total, 56 participants were consented for the study. Data collection and analysis occurred iteratively; themes were identified using constant comparison methods. Results Several types of informal communication events were identified and appeared valuable in three ways: (1) providing a better sense of a patient’s baseline function in comparison to their current function; (2) gaining a more holistic understanding of the patient’s needs; and (3) generating better insight into a patient’s wishes and goals of care. Participants identified a number of organisational and communication challenges leading to the need for informal communication events. These included: scheduling, competing demands and the spatial and temporal organisation of the ward. As a result, nursing staff, allied health professionals and caregivers had to develop strategies for interacting with the physician team. Conclusion We highlight the importance of informal communication in supporting patient care and the gaps in the system contributing to their necessity. Changes at the system level are needed to ensure we are not leaving important collaborative opportunities to chance alone.

Globalization and History Education: The United States and Canada

This chapter explores the role of history education in imagining the nations of the United States and Canada within the global order. I provide an overview of the discourses of national identity and relevant research on history education in each nation. Observing three US and two Canadian secondary history classes engaged in the study of World War II, I identify the schematic narrative templates that render the United States as a “reluctant hegemon” and Canada as uncertain of its claim to nationhood. The US story of the World War II as a fundamentally political narrative suggests an underlying narrative in which politics, rather than military or economic actions, are the driving force in history. Canadian narratives, on the other hand, portray different images of the war. Not only do military narratives dominate the narrative landscape, but the narratives attend in detail to the material experiences of ordinary soldiers. The chapter concludes with a discussion of the need to critically read and rewrite the national narrative.