Lorelei Lingard

Learning from clinical work: the roles of learning cues and credibility judgements.

Medical Education 2012: 46 : 192–200

Are we all on the same page? A discourse analysis of interprofessional collaboration.

Purpose Interprofessional collaboration (IPC) has become a dominant idea in both medical education and clinical care as reflected in its incorporation into competency-based educational frameworks and hospital accreditation models. This study examined the published literature to explore whether a shared IPC discourse underpins these current efforts. Method Using a critical discourse analysis methodology informed by Michel Foucault’s approach, the authors analyzed an archive of 188 texts published from 1960 through 2011. The authors identified the texts through a search of PubMed and CINAHL. Results The authors identified two major discourses in IPC: utilitarian and emancipatory. The utilitarian discourse is characterized by a positivist, experimental approach to the question of whether IPC is useful in patient care and, if so, what features best promote successful outcomes. This discourse uses the language of “evidence” and “validity.” The emancipatory discourse is characterized by a constructivist approach concerned primarily with equalizing power relations among health practitioners; its language includes “power” and “dominance.” Conclusions This study suggests that IPC is not a single, coherent idea in medical education and health care. At least two different IPC discourses exist, each with its own distinctive truths, objects, and language. The extent to which educators and health care practitioners may tacitly align with one discourse or the other may explain the tensions that have accompanied the conceptualization, implementation, and assessment of IPC. Explicit acknowledgment of and attention to these discourses could improve the coherence and impact of IPC efforts in educational and clinical settings.

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

CONTEXTnThere is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team.nnnOBJECTIVESnTo design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team.nnnMETHODSnThis article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams.nnnRESULTSnWe describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps.nnnCONCLUSIONnWe anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Progressive collaborative refinement on teams: implications for communication practices

Medical teaching teams (MTTs) must balance teaching and patient care in the face of three challenges: shifting team membership, varying levels of learners and patient complexity. To support care, MTTs rely on a combination of recurrent oral and written communication practices (genres), such as admission, progress and discharge notes. The purpose of this study was to explore how these genres influence the teams ability to collectively care for patients.

To stay or not to stay? A grounded theory study of residents' postcall behaviors and their rationalizations for those behaviors.

Purpose Although policies to restrict residents’ duty hours are pervasive, resident adherence to restricted duty hours has proved challenging. The authors sought to describe residents’ postcall behaviors and understand the dominant rationalizations underpinning their decisions to stay or not to stay after a 24-hour shift. Method Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 24 residents across six surgical and nonsurgical specialty programs at one Canadian institution during 2012. They analyzed transcripts iteratively using a constant comparative method of identifying and refining key themes as the data set accrued, and theoretically sampling until theme saturation. Results Abiding by cultural norms was the dominant rationalization for both choosing to continue to work postcall or to go home. Cutting across this dominant theme were three subcategories (infrastructure, invoking values, and negotiating tension) with a pattern of residents invoking similar values of patient safety and education regardless of the cultural norms of their program, the infrastructure within which they worked, or the tensions they were navigating. Conclusions Although central to residents’ rationalizations, values appear to be versatile, amenable to multiple, even conflicting, applications. Residents perceived that they were upholding the values of patient safety and education regardless of which postcall behavior they chose—staying or going. Based on this, for duty hours reform initiatives to be successful, a shift to emphasizing organizational changes will be required to reduce the circumstances in which postcall behavior is an individual, values-based decision.

Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do?

Purpose In clinical settings, uncertainty is part of everyday practice. However, a lack of insight into how experts approach uncertainty limits the ability to explicitly teach and assess it in training. This study explored how experienced surgeons perceived and handled uncertainty during challenging intraoperative situations, to develop a theoretical language supporting both education and research. Method This constructivist qualitative study included observations and interviews during 26 surgical cases. The cases, drawn from seven staff surgeons from various specialties at a medical school, were purposively sampled after being preidentified by the surgeon as “likely challenging.” The authors combined template and inductive analyses. In template analysis, an existing theory was used to identify instances of uncertainty in the dataset. Inductive analysis was used to elaborate and refine the concepts. Results Template analysis confirmed that existing theoretical concepts are relevant to surgery. However, inductive analysis revealed additional concepts and positioned existing concepts within new relationships. Two new theoretical themes were recognizing uncertainty and responding to uncertainty, each with corresponding subthemes. Factors such as the novelty of the situation, difficulty in predicting the outcome, and difficulty deciding the course of action mainly characterize an uncertain situation in surgery according to the participants. Conclusions The results offer a refined language for conceptualizing uncertainty in surgery. Although further research could elaborate and test the explanatory power of this language, the authors anticipate that it has implications both for current discussions of surgical safety and for future development of explicit training for effective management of surgical uncertainty.

Old News: Why the 90‐Year Crisis in Medical Elder Care?

North American and European demographic projections indicate that by 2030, persons aged 65 and older will outnumber those younger than 15 by a ratio of 2:1. Curiously, principles of geriatric care have not taken strong hold among nongeriatric specialties, even as we approach the time of greatest need. To explore historical precedents for the current crisis in elder care, this article revisits the prescriptions of G. Stanley Halls Senescence: The Last Half of Life (1922), a text widely recognized as one of the founding texts in the medicalized study of aging. It presents in brief three of Halls major concerns—paucity of knowledge of nongeriatric specialists, the need for individualized care of elderly adults, and the prevalence of attitudinal obstacles in medical professionals caring for older persons—to demonstrate how little the language and content of modern appraisals have evolved since 1922. This disconcerting sense of paralysis is presented as an opportunity to advance important questions aimed at stimulating a more‐comprehensive research agenda for addressing the future of medical elder care.

Engaged at the extremes: residents' perspectives on clinical teaching assessment.

Purpose Although academic centers rely on assessments from medical trainees regarding the effectiveness of their faculty as teachers, little is known about how trainees conceptualize and approach their role as assessors of their clinical supervisors. Method In 2010, using a constructivist grounded theory approach, five focus group interviews were conducted with 19 residents from an internal medicine residency program. A constant comparative analysis of emergent themes was conducted. Results Residents viewed clinical teaching assessment (CTA) as a time-consuming task with little reward. They reported struggling throughout the academic year to meet their CTA obligations and described several shortcut strategies they used to reduce their burden. Rather than conceptualizing their assessments as a conduit for both formative and summative feedback, residents perceived CTA as useful for the surveillance of clinical supervisors at the extremes of the spectrum of teaching effectiveness. They put the most effort, including the crafting of written comments, into the CTAs of these outliers. Trainees desired greater transparency in the CTA process and were skeptical regarding the anonymity and perceived validity of their faculty appraisals. Conclusions Individual and system-based factors conspire to influence postgraduate medical trainees’ motivation for generating high-quality appraisals of clinical teaching. Academic centers need to address these factors if they want to maximize the usefulness of these assessments.