Rola Ajjawi

The "educational alliance" as a framework for reconceptualizing feedback in medical education.

Feedback has long been considered a vital component of training in the health professions. Nonetheless, it remains difficult to enact the feedback process effectively. In part, this may be because, historically, feedback has been framed in the medical education literature as a unidirectional content-delivery process with a focus on ensuring the learner’s acceptance of the content. Thus, proposed solutions have been organized around mechanistic, educator-driven, and behavior-based best practices. Recently, some authors have begun to highlight the role of context and relationship in the feedback process, but no theoretical frameworks have yet been suggested for understanding or exploring this relational construction of feedback in medical education. The psychotherapeutic concept of the “therapeutic alliance” may be valuable in this regard. In this article, the authors propose that by reorganizing constructions of feedback around an “educational alliance” framework, medical educators may be able to develop a more meaningful understanding of the context—and, in particular, the relationship—in which feedback functions. Use of this framework may also help to reorient discussions of the feedback process from effective delivery and acceptance to negotiation in the environment of a supportive educational relationship. To explore and elaborate these issues and ideas, the authors review the medical education literature to excavate historical and evolving constructions of feedback in the field, review the origins of the therapeutic alliance and its demonstrated utility for psychotherapy practice, and consider implications regarding learners’ perceptions of the supervisory relationship as a significant influence on feedback acceptance in medical education settings.

Shedding the cobra effect: problematising thematic emergence, triangulation, saturation and member checking

Qualitative research is widely accepted as a legitimate approach to inquiry in health professions education (HPE). To secure this status, qualitative researchers have developed a variety of strategies (e.g. reliance on post‐positivist qualitative methodologies, use of different rhetorical techniques, etc.) to facilitate the acceptance of their research methodologies and methods by the HPE community. Although these strategies have supported the acceptance of qualitative research in HPE, they have also brought about some unintended consequences. One of these consequences is that some HPE scholars have begun to use terms in qualitative publications without critically reflecting on: (i) their ontological and epistemological roots; (ii) their definitions, or (iii) their implications.

Core components of communication of clinical reasoning: a qualitative study with experienced Australian physiotherapists

Communication is an important area in health professional education curricula, however it has been dealt with as discrete skills that can be learned and taught separate to the underlying thinking. Communication of clinical reasoning is a phenomenon that has largely been ignored in the literature. This research sought to examine how experienced physiotherapists communicate their clinical reasoning and to identify the core processes of this communication. A hermeneutic phenomenological research study was conducted using multiple methods of text construction including repeated semi-structured interviews, observation and written exercises. Hermeneutic analysis of texts involved iterative reading and interpretation of texts with the development of themes and sub-themes. Communication of clinical reasoning was perceived to be complex, dynamic and largely automatic. A key finding was that articulating reasoning (particularly during research) does not completely represent actual reasoning processes but represents a (re)construction of the more complex, rapid and multi-layered processes that operate in practice. These communications are constructed in ways that are perceived as being most relevant to the audience, context and purpose of the communication. Five core components of communicating clinical reasoning were identified: active listening, framing and presenting the message, matching the co-communicator, metacognitive aspects of communication and clinical reasoning abilities. We propose that communication of clinical reasoning is both an inherent part of reasoning as well as an essential and complementary skill based on the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined, providing evidence for the argument that they should be learned (and explicitly taught) in synergy and in context.

The construction of power in family medicine bedside teaching: a video observation study.

Introduction  Bedside teaching is essential for helping students develop skills, reasoning and professionalism, and involves the learning triad of student, patient and clinical teacher. Although current rhetoric espouses the sharing of power, the medical workplace is imbued with power asymmetries. Power is context‐specific and although previous research has explored some elements of the enactment and resistance of power within bedside teaching, this exploration has been conducted within hospital rather than general practice settings. Furthermore, previous research has employed audio‐recorded rather than video‐recorded observation and has therefore focused on language and para‐language at the expense of non‐verbal communication and human–material interaction.

Researching feedback dialogue: an interactional analysis approach

A variety of understandings of feedback exist in the literature, which can broadly be categorised as cognitivist information transmission and socio-constructivist. Understanding feedback as information transmission or ‘telling’ has until recently been dominant. However, a socio-constructivist perspective of feedback posits that feedback should be dialogic and help to develop students’ ability to monitor, evaluate and regulate their learning. This paper is positioned as part of the shift away from seeing feedback as input, to exploring feedback as a dialogical process focusing on effects, through presenting an innovative methodological approach to analysing feedback dialogues in situ. Interactional analysis adopts the premise that artefacts and technologies set up a social field, where understanding human–human and human–material activities and interactions is important. The paper suggests that this systematic approach to analysing dialogic feedback can enable insight into previously undocumented aspects of feedback, such as the interactional features that promote and sustain feedback dialogue. The paper discusses methodological issues in such analyses and implications for research on feedback.

Marginalisation of dental students in a shared medical and dental education programme

Objectives  Internationally, there are a number of universities at which medical and dental education programmes share common elements. There are no studies about the experiences of medical and dental students enrolled in different programmes who share significant amounts of learning and teaching.

Feedback and the educational alliance: examining credibility judgements and their consequences

Several recent studies have documented the fact that, in considering feedback, learners are actively making credibility judgements about the feedback and its source. Yet few have intentionally explored such judgements to gain a deeper understanding of how the process works or how these judgements might interact to influence engagement with and interpretation of feedback. Using the educational alliance framework, we sought to elaborate an understanding of learners’ credibility judgements and their consequences.

Promoting clinical reasoning in general practice trainees: role of the clinical teacher

Background:  Clinical reasoning requires knowledge, cognition and metacognition, and is contextually bound. Clinical teachers can and should play a key role in explicitly promoting clinical reasoning.

Family physician preceptors' conceptualizations of health advocacy: implications for medical education.

Purpose Despite its official acceptance as an important physician responsibility, health advocacy remains difficult to define, teach, role model, and assess. The aim of the current study was to explore physicians’ conceptions of health advocacy based on their experience with health-advocacy-related activities. Method In 2012, the authors conducted 11 semistructured interviews with family physician clinical preceptors and analyzed the interviews in the tradition of phenomenography. Results The authors identified three distinct but related ways of understanding health advocacy: (1) Clinical: Health advocacy as support of individual patients in addressing health care needs related to the immediate clinical problem within the health care system, (2) Paraclinical: Health advocacy as support of individual patients in addressing needs that the physician preceptors viewed as peripheral yet parallel to both the health care system and the immediate clinical problem, and (3) Supraclinical: Health advocacy as population-based activities aimed at practice- and system-level changes that address the social determinants of health. Conclusions The qualitatively different understandings of health advocacy shed light on why current approaches to defining, teaching, role modeling, and assessing health advocacy competencies in medical education appear idiosyncratic. The authors suggest the development of an inclusive and extensive conceptual framework that may allow the medical education community to imagine novel ways of understanding and engaging in health advocacy.

‘Is there a Plan B?’: clinical educators supporting underperforming students in practice settings

The relationship between supervisors and students in work-based clinical settings is complex, but critical to the appropriate development of the learner. This study investigated the experiences of physiotherapy clinical educators of working with underperforming students, and specifically explored educational strategies used with this subgroup of learners. Findings indicated the cyclical relationship between clinical educators stressful experiences of working in multifaceted roles within a clinical environment and their tendencies to provide ‘more more more’ – more of the same strategies, more feedback and supervision, and more of themselves – as their primary approach to supporting underperforming students. The data suggest that clinical educators did not have an alternative (‘Plan B’) if the ‘more more more’ approach did not produce results. We argue that the problem of managing underperforming students is a complex one without easy solutions but a focus on systems changes rather than upon individual students or clinical educators should be considered.