Only When They Seek: Exploring Supervisor and Resident Perspectives and Positions on Upward Feedback.

INTRODUCTION: Verbal feedback from trainees to supervisors is rare in medical education, although valuable for improvement in teaching skills. Research has mostly examined narrative comments on resident evaluations of their supervisors. This study aimed to explore supervisors' and residents' beliefs and experiences with upward feedback, along with recommendations to initiate and facilitate effective conversations. METHODS: Using 60-minute focus group discussions, a previous study explored opinions of internal medicine residents and clinical supervisors at the Brigham and Women's Hospital regarding the impact of institutional culture on feedback conversations. For this study, we conducted a thematic analysis of the transcribed, anonymous data to identify key concepts pertaining only to verbal upward feedback, through the theoretical lens of Positioning theory. RESULTS: Twenty-two supervisors and 29 residents participated in three and five focus groups, respectively. Identified themes were mapped to three research questions regarding (1) existing beliefs (lack of impact, risks to giving supervisors feedback, need for preparation and reflection), (2) experiences (nonspecific language, avoidance of upward feedback, bypassing the supervisor), and (3) recommended approaches (setting clear expectations, seeking specific feedback, emphasizing interest in growth). DISCUSSION: Study participants appeared to assume learner-teacher positions during feedback conversations, resulting in residents' concerns of adverse consequences, beliefs that supervisors will neither accept feedback nor change their behaviors, and avoidance of constructive upward feedback. Residents suggested that emphasis on mutual professional growth and regular feedback seeking by supervisors could encourage them to take on the role of feedback providers. Their recommendations could be a valuable starting point for faculty development initiatives on upward feedback.

Fundamental Teaching Activities in Family Medicine Framework: Analysis of Awareness and Utilization.

INTRODUCTION: In 2015, the College of Family Physicians of Canada, in performing their commitment to supporting its members in their educational roles, created the Family Medicine Framework (FTA). It was designed to assist family medicine educators with an understanding of the core activities of educators: precepting, coaching, and teaching within or beyond clinical settings. Given that an examination of member awareness of FTA has not been previously undertaken, our primary objective was to conduct an evaluation on its utility and application. METHODS: In partnership with College of Family Physicians of Canada Faculty Development Education Committee members, we used a practical participatory evaluation approach to conduct a two-phase mixed-methods evaluation of the FTA. We distributed an electronic survey in French and English languages to Canadian faculty development, program, and site directors in family medicine. We then conducted follow-up interviews with self-selected participants. RESULTS: Of the target populations, 12/15 (80%) faculty development directors (FDDs), 12/18 (66.7%) program directors, and 34/174 (19.5%) site directors completed the electronic survey. Subsequently, 6 FDDs, 3 program directors, and 3 site directors completed an interview (n = 12). Findings indicate that awareness of the FTA was highest among FDDs. Facilitators who encourage teachers to use the FTA and barriers for low uptake were also identified. DISCUSSION: This evaluation illuminated that varied levels of awareness of the FTA may contribute to the low uptake among education leaders. We also suggest future research to address possible barriers that hinder effective applications of the FTA in faculty development initiatives.

Children's Pain During IV Induction: A Randomized-Controlled Trial With the MEDi® Robot.

OBJECTIVE: This study examined the impact of a humanoid robot (MEDi®) programmed to teach deep breathing as a coping strategy, on children's pain and fear as primary and secondary outcomes, respectively, during intravenous (IV) line placement. The completion of IV induction was also examined as an exploratory outcome. METHODS: In this randomized controlled, two-armed trial, 137 children (4-12 years) were recruited in Short Stay Surgery at a tertiary pediatric hospital. Patients were randomly assigned to standard care (SC) with Ametop© only (N = 60) or SC and robot-facilitated intervention (N = 59) before induction. Pain and fear before, during, and after IV insertion were rated by patients and observers. RESULTS: No significant differences were found between groups and there were no changes over time for pain or fear (ps > .05). Exploratory analyses show that patients in the MEDi® group were 5.04 times more likely to complete IV induction, compared to SC, Fisher's exact test: X2 (1) = 4.85, p = .04, φc = 0.22, odds ratio = 5.04, 95% CI [1.06, 24.00]. CONCLUSION: This study was the first to examine children's IV induction experience when provided MEDi® support. Reasons for nonsignificance, limitations, and research suggestions were made.

Barriers and Facilitators to Using Statins: A Qualitative Study With Patients and Family Physicians.

BACKGROUND: Despite their proven efficacy to reduce cardiovascular disease, statin medication use remains low in individuals at high risk of cardiovascular disease considering their widespread availability and safety. Our objective was to explore the perspectives of patients and family physicians with regard to the barriers and facilitators of statin use in primary care. METHODS: In this qualitative descriptive study, we conducted 2 focus groups with patients (number, n = 8/6) and individual semistructured interviews with family physicians (n = 17) from community settings. Interviewers asked participants about barriers to and facilitators of statin use. Focus groups and interviews were digitally recorded, transcribed, and analyzed in duplicate using conventional content analysis. RESULTS: Patients were averse to taking statins for a variety of reasons: medication avoidance and burden; inadequate buy-in for statin therapy; and difficulty remembering to take statins regularly. Family physicians perceived similar barriers and reported other barriers: lack of resources such as inadequate tracking systems; specialist-primary care provider guideline discordance; and lack of continuity and relationship. Patients expressed that key facilitators were patient education and support; splitting tablets to increase cost-effectiveness; and changing to a different statin or lower dose in those with side effects. Family physicians described several similar strategies to facilitate therapy as well as shared decision making and clinical decision support tools as enablers for improvement. CONCLUSIONS: We identified several important barriers to and facilitators of statin use at the patient and prescriber level. This information offers insight into strategies to improve statin use and the development of innovative programs and interventions.

INTRODUCTION: En dépit de leur efficacité prouvée pour réduire les maladies cardiovasculaires, l'utilisation des statines reste faible chez les individus exposés à un risque élevé de maladies cardiovasculaires si l'on considère leur grande disponibilité et leur innocuité. Notre objectif était d'examiner les perspectives des patients et des médecins de famille en ce qui concerne les obstacles et les facilitateurs de l'utilisation des statines en soins primaires. MÉTHODES: Dans la présente étude qualitative descriptive, nous avons mené 2 groupes de discussion composés de patients (nombre, n = 8/6) et des entrevues semi-structurées individuelles avec des médecins de famille (n = 17) en milieu communautaire. Les intervieweurs ont demandé aux participants quels étaient les obstacles et les facilitateurs de l'utilisation des statines. Les groupes de discussion et les entrevues étaient enregistrés numériquement, transcrits et analysés en duplicata à l'aide de l'analyse de contenu traditionnelle. RÉSULTATS: Les patients se sont opposés à la prise de statines pour plusieurs raisons : l'évitement et le fardeau des médicaments, l'adhésion insuffisante au traitement par statines et la difficulté à se souvenir de prendre régulièrement les statines. Les médecins de famille ont perçu des obstacles similaires et ont rapporté d'autres obstacles dont le manque de ressources telles que les systèmes de suivi inadéquats, la divergence entre les orientations des spécialistes et des prestataires de soins primaires, et le manque de continuité et de relation. Les patients ont exprimé que les principaux facilitateurs étaient l'éducation et le soutien offerts aux patients; le fractionnement des comprimés pour améliorer l'efficience; le changement vers une statine différente ou une dose plus faible chez ceux qui présentent des effets secondaires. Les médecins de famille ont décrit plusieurs stratégies semblables pour faciliter le traitement ainsi que la prise de décision partagée et les outils d'aide à la décision clinique qui facilitent l'amélioration. CONCLUSIONS: Nous avons déterminé plusieurs obstacles et facilitateurs importants de l'utilisation des statines au point de vue du patient et du prescripteur. Ces informations offrent un aperçu des stratégies pour améliorer l'utilisation des statines et l'élaboration d'interventions et de programmes innovateurs.

Strategies for enhancing the initiation of cholesterol lowering medication among patients at high cardiovascular disease risk: a qualitative descriptive exploration of patient and general practitioners' perspectives on a facilitated relay intervention in Alberta, Canada.

OBJECTIVE: The objective of our study was to explore the perspectives of patients and general practitioners (GPs) regarding interventions to increase initiation of cholesterol lowering medication (or statins), including a proposed laboratory-based facilitated relay intervention. DESIGN: Qualitative descriptive study using interviews and focus groups for data collection, and thematic analysis for data analysis. SETTING: Primary care providers and patients in Calgary, Alberta, Canada. PARTICIPANTS: 17 GPs with primarily community-based, non-academic practices with at least 1 year of practice experience participated in semistructured interviews. 14 patients at high risk of cardiovascular disease participated in focus groups. MAIN OUTCOME MEASURES: Exploration of strategies that might be used to enhance the prescription of, and adherence to statin therapy for patients with statin-indicated conditions. RESULTS: GPs proposed a variety of interventions to improve statin prescription, including electronic record audit solutions, GP directed education, and patient-oriented campaigns. Patients expressed that they may benefit from being provided access to their laboratory test results, as well as targeted education. Both parties provided positive feedback on the proposed laboratory-based facilitated relay intervention, while pointing out areas for improvement. Notably, GPs were concerned that the patient-directed component of the intervention might jeopardise therapeutic relationships, and patients were concerned about accidental disclosure of personal health information. Important considerations for the design of facilitated relay messaging should include brevity, simplicity and the provision of contact information for inquiries. CONCLUSIONS: GPs and patients described several suggestions for increasing statin initiation and welcomed the proposal of a laboratory-based facilitated relay strategy. These findings support further testing of this intervention which may enhance GPs' ability to successfully engage patients in cardiovascular risk reduction through statin therapy.

In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context.

BACKGROUND: The R2C2, a 4-phase feedback and coaching model, builds relationships, explores reactions, determines content and coaches for change, and facilitates formal feedback conversations between clinical supervisors/preceptors and residents. Formal discussions about performance are typically based on collated information from daily encounter sheets, objective structured clinical examinations, multisource feedback, and other data. This model has not been studied in settings where brief feedback and coaching conversations occur immediately after a specific clinical experience. OBJECTIVE: We explored how supervisors adapt the R2C2 model for in-the-moment feedback and coaching and developed a guide for its use in this context. METHODS: Eleven purposefully selected supervisors were interviewed in 2018 to explore where they used the R2C2 model, how they adapted it for in-the-moment conversations, and phrases used corresponding to each phase that could guide design of a new R2C2 in-the-moment model. RESULTS: Participants readily adapted the model to varied feedback situations; each of the 4 phases were relevant for conversations. Phase-specific phrases that could enable effective coaching conversations in a limited amount of time were identified. Data facilitated a revision of the original R2C2 model for in-the-moment feedback and coaching conversations and design of an accompanying trifold brochure to enable its effective use. CONCLUSIONS: The R2C2 in-the-moment model offers a systematic approach to feedback and coaching that builds on the original model, yet addresses time constraints and the need for an iterative conversation between the reaction and content phases. The model enables supervisors to coach and co-create an action plan with residents to improve performance.