Luc Côté

Appraising qualitative research articles in medicine and medical education

Although qualitative research is gaining recognition in medicine and in medical education, most clinical teachers do not know how to perform a critical appraisal of articles in these fields. This article describes a grid for the critical appraisal of qualitative research articles so that clinical teachers are in a better position to evaluate this type of research and to teach the critical appraisal of it. The grid is comprised of 12 items with an explanation and suggestions for additional reading for each item.

How clinical teachers perceive the doctor-patient relationship and themselves as role models.

Purpose Teachers must be good role models. In order to act the part, however, they must reflect on and articulate the attitudes and behaviors they wish to convey. The aim of this study was to describe how clinicians who teach clerks and residents represent the doctor—patient relationship and how they see themselves as role models for this relationship. Method In the fall of 1997, 28 clinical teachers in family medicine and various medical and surgical specialties at Laval University Faculty of Medicine participated in individual semistructured interviews regarding their perceptions of the doctor—patient relationship and how it is taught. The interviews were conducted by a trained research assistant and the content of the interviews was coded by three independent observers, who then performed a qualitative analysis. Results The clinical teachers identified competencies associated with the doctor—patient relationship that differed in complexity and specificity. Paramount among these competencies were the ability to conduct interviews effectively and politely, the ability to understand and involve the patient, and, in some cases, the ability to handle emotionally-charged situations. The clinical teachers tended to demand more of their students in doctor—patient relationships than they did of themselves. Lack of time and a negative attitude toward the doctor—patient relationship, on the part of both teachers and students, were obstacles to teaching and learning this essential competency, even to the point of making it difficult for teachers to demonstrate and supervise these competencies during their daily clinical activities. Conclusions Most of the teachers had difficulty describing situations or behaviors in which they modeled the doctor—patient relationship. Being a role model requires a fairly precise idea of what one is modeling and accomplishing, and what one wants trainees to understand about the relationship. Efforts must be made to help clinical teachers to integrate the doctor—patient relationship into their clinical supervision and to provide them with tools to demonstrate this relationship effectively.

Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial.

Background  Experts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs).

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools.

The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre‐clinical and clinical students shared the same perceptions.

The limitations of a negotiation model for perimenopausal women

The clinical negotiation model proposed by Katon and Kleinman (1981) puts culture at the very heart of the patient-doctor relationship. As opposed to the asymmetric model that stresses an unequal power relationship between a dominant physician and a powerless patient, this transactional model suggests that we view the clinical encounter as the locus of a negotiation that takes place between two kinds of knowledge (lay and professional), and between two agendas: the doctor’s and the patient’s. According to such a model, the doctor is taught to listen to the patient’s own explanatory model of disease. Using an in-depth analysis of clinical encounters between perimenopausal women and female physicians, and of separate interviews with individual doctors and patients concerning their respective explanatory models, this pilot study puts emphasis on both the limitations of a transactional model and on the strategies deployed by doctors for enhancing the credibility of hormonal replacement therapy.

Influences of OSCE design on students' diagnostic reasoning

Some characteristics of assessments exert a strong influence on how students study. Understanding these pre‐assessment learning effects is of key importance to the designing of medical assessments that foster students’ reasoning abilities. Perceptions of the task demands of an assessment significantly influence students’ cognitive processes. However, why and how certain tasks positively ‘drive’ learning remain unknown. Medical tasks can be assessed as coherent meaningful whole tasks (e.g. examining a patient based on his complaint to find the diagnosis) or can be divided into simpler part tasks (e.g. demonstrating the physical examination of a pre‐specified disease). Comparing the benefits of whole‐task and part‐task assessments in a randomised controlled experiment could guide the design of ‘assessments for learning’.

Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial

BackgroundThe misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.MethodsA pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.ResultsAmong 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.ConclusionsThis trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.Trial RegistrationClinicaltrials.Gov NCT00354315

Content and conceptual frameworks of preceptor feedback related to residents' educational needs.

Purpose The development of clinical expertise depends not only on frequent practice opportunities but also on receiving quality feedback, especially regarding difficult aspects of learning. The purpose of this study was to investigate the content and conceptual frameworks of preceptor feedback to residents during case presentations. Method The authors conducted a qualitative and correlational study in which 25 clinical preceptors from one Canadian medical school’s internal medicine and family medicine residency programs responded to six written, case-based vignettes depicting residents seeking help regarding a variety of educational issues. Preceptors were asked probing follow-up questions about their responses. The authors analyzed response content, conceptual frameworks used in formulating responses, and the correlation between the two. Results Overall, the preceptors generated 806 responses, representing 96 distinct topics. The five topics mentioned most frequently related to reading suggestions, leading diagnosis, contrasting clinical findings, patient follow-up, and resident’s concerns/feelings about the case. Seventy-three percent of the topics were specific to one or two vignettes. The preceptors used 18 distinct conceptual frameworks in formulating responses (e.g., analytical versus nonanalytical reasoning, problem representation, therapeutic alliance, patient-centered approach). Use of conceptual frameworks was positively associated with greater diversity of responses (r = 0.43, P = .03). Conclusions The vignettes stimulated rich and extensive lists of topics and conceptual frameworks. These findings represent but one step in the exploration of the content and conceptual frameworks of preceptor feedback and of the interrelatedness of feedback content and process, which have important implications for teaching and faculty development.

Preceptors' understanding and use of role modeling to develop the CanMEDS competencies in residents.

Purpose Role modeling by preceptors is a key strategy for training residents in the competencies defined within the CanMEDS conceptual framework. However, little is known about the extent to which preceptors are aware of the importance of role modeling or how they perceive and enact it in their daily interactions with residents. The purpose of this study was to describe how preceptors understand and use role modeling to develop CanMEDS competencies in residents. Method In 2010, the authors conducted a descriptive qualitative study with preceptors in medical, surgical, and laboratory specialties who supervised residents on a regular basis at the Université Laval Faculty of Medicine (Québec, Canada). Respondents participated in semistructured, individual interviews. An inductive thematic analysis of interview transcripts was conducted using triangulation. Results Most participants highlighted the importance of role modeling to support residents’ development of the CanMEDS competencies, particularly communication, collaboration, and professionalism, which preceptors perceived as “less scientific” and the most difficult to teach. Although most participants reported using an implicit, unstructured role modeling process, some described more explicit strategies. Eight types of educational challenges in role modeling the CanMEDS competencies were identified, including encouraging reflective practice, understanding the competencies and their importance in one’s specialty, and being aware of one’s strengths and weaknesses as a clinical teacher. Conclusions Preceptors are aware of the importance of role modeling competencies for residents, but many do so only implicitly. This study’s findings are important for improving strategies for role modeling and for the professional development of preceptors.

Student Uncertainties Drive Teaching During Case Presentations: More So With Snapps

Purpose To compare the nature of uncertainties expressed by medical students using the six-step SNAPPS technique for case presentations (Summarize history and findings; N>arrow the differential; Analyze the differential; Probe preceptors about uncertainties; Plan management; Select case-related issues for self-study) versus those expressed by students doing customary presentations and to elucidate how preceptors respond. Method The authors performed a secondary analysis in 2009 of data from a 2004–2005 randomized study, comparing SNAPPS users’ case presentations with other students’ presentations. Authors coded transcriptions of audiotaped presentations to family medicine preceptors for type of student uncertainties, nature of preceptor responses, alignment of preceptor responses with uncertainty types, and expansion of preceptors’ responses beyond addressing uncertainties. Results The analysis included 19 SNAPPS and 41 comparison presentations. SNAPPS students expressed uncertainties in all case presentations, nearly twice as many as the comparison group (&khgr;21df = 12.89, P = .0001). Most SNAPPS users’ uncertainties (24/44 [55%]) focused on diagnostic reasoning compared with 9/38 (24%) for comparison students’ (&khgr;21df = 8.08, P = .004). Uncertainties about clinical findings and medications/management did not differ significantly between groups. Preceptors responded with teaching aligned with the uncertainties and expanded 24/66 (36%) of their comments. Conclusion Students can drive the content of the teaching they receive based on uncertainties they express to preceptors during case presentations. Preceptors are ready to teach at “the drop of a question” and align their teaching with the content of students’ questions; these learning moments—in context and just-in-time—can be created by students.