Pim W. Teunissen

How residents learn: qualitative evidence for the pivotal role of clinical activities

Objectives  Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace.

Introducing competency-based postgraduate medical education in the Netherlands

Medical boards around the world face the challenge of creating competency-based postgraduate training programs. Recent legislation requires that all postgraduate medical training programmes in The Netherlands be reformed.  In this article the Dutch Advisory Board for Postgraduate Curriculum Development shares some of their experiences with guiding the design of specialist training programs, based on the Canadian Medical Educational Directives for Specialists (CanMEDS).  All twenty-seven Dutch Medical Specialty Societies take three steps in designing a curriculum. First they divide the entire content of a specialty into logical units, so-called ‘themes’. The second step is discussing, for each theme, for which tasks trainees have to be instructed, guided, and assessed. Finally, for each task an assessment method is chosen to focus on a limited number of CanMEDS roles.  This leads to a three step training cycle: (i) based on their in-training assessment and practices, trainees will gather evidence on their development in a portfolio; (ii) this evidence stimulates the trainee and the supervisor to regularly reflect on a trainees global development regarding the CanMEDS roles as well as on the performance in specific tasks; (iii) a personal development plan structures future learning goals and strategies.  The experiences in the Netherlands are in line with international developments in postgraduate medical education and with the literature on workplace-based teaching and learning.

Opportunity or threat: the ambiguity of the consequences of transitions in medical education

Medical Education 2011: 45: 51–59

Experiential learning: AMEE guide No. 63

This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is ‘situated’; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.

Who Wants Feedback? An Investigation of the Variables Influencing Residents' Feedback- Seeking Behavior in Relation to Night Shifts

Purpose The literature on feedback in clinical medical education has predominantly treated trainees as passive recipients. Past research has focused on how clinical supervisors can use feedback to improve a trainee’s performance. On the basis of research in social and organizational psychology, the authors reconceptualized residents as active seekers of feedback. They investigated what individual and situational variables influence residents’ feedback-seeking behavior on night shifts. Method Early in 2008, the authors sent obstetrics–gynecology residents in the Netherlands—both those in their first two years of graduate training and those gaining experience between undergraduate and graduate training—a questionnaire that assessed four predictor variables (learning and performance goal orientation, and instrumental and supportive leadership), two mediator variables (perceived feedback benefits and costs), and two outcome variables (frequency of feedback inquiry and monitoring). They used structural equation modeling software to test a hypothesized model of relationships between variables. Results The response rate was 76.5%. Results showed that residents who perceive more feedback benefits report a higher frequency of feedback inquiry and monitoring. More perceived feedback costs result mainly in more feedback monitoring. Residents with a higher learning goal orientation perceive more feedback benefits and fewer costs. Residents with a higher performance goal orientation perceive more feedback costs. Supportive physicians lead residents to perceive more feedback benefits and fewer costs. Conclusions This study showed that some residents actively seek feedback. Residents’ feedback-seeking behavior partially depends on attending physicians’ supervisory style. Residents’ goal orientations influence their perceptions of the benefits and costs of feedback-seeking.

Assessment of competence and progressive independence in postgraduate clinical training

Context  At present, competency‐based, outcome‐focused training is gradually replacing more traditional master–apprentice teaching in postgraduate training. This change requires a different approach to the assessment of clinical competence, especially given the decisions that must be made about the level of independence allowed to trainees.

Psychometric properties of an instrument to measure the clinical learning environment

Objectives  The clinical learning environment is an influential factor in work‐based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training).

Workplace Learning from a Socio-Cultural Perspective: Creating Developmental Space during the General Practice Clerkship.

Workplace learning in undergraduate medical education has predominantly been studied from a cognitive perspective, despite its complex contextual characteristics, which influence medical students’ learning experiences in such a way that explanation in terms of knowledge, skills, attitudes and single determinants of instructiveness is unlikely to suffice. There is also a paucity of research which, from a perspective other than the cognitive or descriptive one, investigates student learning in general practice settings, which are often characterised as powerful learning environments. In this study we took a socio-cultural perspective to clarify how students learn during a general practice clerkship and to construct a conceptual framework that captures this type of learning. Our analysis of group interviews with 44 fifth-year undergraduate medical students about their learning experiences in general practice showed that students needed developmental space to be able to learn and develop their professional identity. This space results from the intertwinement of workplace context, personal and professional interactions and emotions such as feeling respected and self-confident. These forces framed students’ participation in patient consultations, conversations with supervisors about consultations and students’ observation of supervisors, thereby determining the opportunities afforded to students to mind their learning. These findings resonate with other conceptual frameworks and learning theories. In order to refine our interpretation, we recommend that further research from a socio-cultural perspective should also explore other aspects of workplace learning in medical education.

Development and analysis of D-RECT, an instrument measuring residents’ learning climate

Background: Measurement of learning climates can serve as an indicator of a departments educational functioning. Aim: This article describes the development and psychometric qualities of an instrument to measure learning climates in postgraduate specialist training: the Dutch Residency Educational Climate Test (D-RECT). Method: A preliminary questionnaire was evaluated in a modified Delphi procedure. Simultaneously, all residents in the Netherlands were invited to fill out the preliminary questionnaire. We used exploratory factor analysis to analyze the outcomes and construct the definitive D-RECT. Confirmatory factor analysis tested the questionnaires goodness of fit. Generalizability studies tested the number of residents needed for a reliable outcome. Results: In two rounds, the Delphi panel reached consensus. In addition, 1278 residents representing 26 specialties completed the questionnaire. The Delphi panels input in combination with the exploratory factor analysis of 600 completed surveys led to the definitive D-RECT, consisting of 50 items and 11 subscales (e.g., feedback, supervision, patient handover and professional relations between attendings). Confirmatory factor analyses of the remaining surveys confirmed the construct. The results showed that a feasible number of residents is needed for a reliable outcome. Conclusion: D-RECT appears to be a valid, reliable and feasible tool to measure the quality of clinical learning climates.

Programmatic assessment of competency-based workplace learning: when theory meets practice

BackgroundIn competency-based medical education emphasis has shifted towards outcomes, capabilities, and learner-centeredness. Together with a focus on sustained evidence of professional competence this calls for new methods of teaching and assessment. Recently, medical educators advocated the use of a holistic, programmatic approach towards assessment. Besides maximum facilitation of learning it should improve the validity and reliability of measurements and documentation of competence development. We explored how, in a competency-based curriculum, current theories on programmatic assessment interacted with educational practice.MethodsIn a development study including evaluation, we investigated the implementation of a theory-based programme of assessment. Between April 2011 and May 2012 quantitative evaluation data were collected and used to guide group interviews that explored the experiences of students and clinical supervisors with the assessment programme. We coded the transcripts and emerging topics were organised into a list of lessons learned.ResultsThe programme mainly focuses on the integration of learning and assessment by motivating and supporting students to seek and accumulate feedback. The assessment instruments were aligned to cover predefined competencies to enable aggregation of information in a structured and meaningful way. Assessments that were designed as formative learning experiences were increasingly perceived as summative by students. Peer feedback was experienced as a valuable method for formative feedback. Social interaction and external guidance seemed to be of crucial importance to scaffold self-directed learning. Aggregating data from individual assessments into a holistic portfolio judgement required expertise and extensive training and supervision of judges.ConclusionsA programme of assessment with low-stakes assessments providing simultaneously formative feedback and input for summative decisions proved not easy to implement. Careful preparation and guidance of the implementation process was crucial. Assessment for learning requires meaningful feedback with each assessment. Special attention should be paid to the quality of feedback at individual assessment moments. Comprehensive attention for faculty development and training for students is essential for the successful implementation of an assessment programme.