Advancing collaboration in health professions education in the general practice domain, developing a national research agenda.

BACKGROUND: Health professions education (HPE) research in the General Practice domain (GP-HPE) is vital for high-quality healthcare. Collaboration among GP-HPE researchers is crucial but challenging. Formulating a research agenda, involving stakeholders, and fostering inter-institutional collaboration can address these challenges and connect educational research and practice. METHODS: We used Q-methodology to explore perspectives on GP-HPE research of participants from all Dutch postgraduate GP training institutes. Participants individually sorted statements based on the relevance of future GP-HPE research for educational practice. Data analysis comprised inverted factor analysis, rotation, and qualitative interpretation of configurations of all statements. The National Meeting on Educational Research took a participatory approach. RESULTS: We included 73 participants with diverse involvement in GP-HPE research. We identified five distinct perspectives, each representing a research focus area for developing and innovating GP education: the clinician scientist, the socially engaged GP, the specific GP identity, the GP as an entrepreneur, and the GP engaged in lifelong learning. DISCUSSION: The resulting five perspectives align with General Practice hallmarks. Q-methodology and a participatory approach facilitated collaboration among stakeholders. Successful inter-institutional collaboration requires a common goal, neutral leadership, participant commitment, regular meetings, audit trail support, process transparency, and reflexivity. Future research should address evidence gaps within these perspectives. CONCLUSION: Using Q-methodology turned out to be valuable for compiling a national research agenda for GP-HPE research. The research process helped to cross boundaries between researchers in different institutions, thus putting inter-institutional collaborative advantage center stage. Our approach could provide a conceivable procedure for HPE researchers worldwide.

Which 'end' do you have in mind? Clinical supervisors' perceptions of professional Identity Formation outcomes in GP residency.

PURPOSE: Professional Identity Formation (PIF) is crucial for high-quality patient care and physician well-being. Few empirical studies examined PIF in residency from the perspective of supervisors. In GP residency, residents are supervised with an 'end in mind' that remains unexplored. To encourage supervisors to reflect on their teaching behaviours, this study investigated GP clinical supervisors' perceptions of PIF outcomes in GP residency. METHODS: Applying qualitative description, focus group interviews were conducted between spring and autumn 2019. Using a semi-structured interview guide, supervisors' perceptions of PIF outcomes were explored. In an iterative coding process applying constant comparison, a thematic analysis was performed of focus group transcripts. RESULTS: We conducted eight focus groups with 55 supervisors at four training institutes across the Netherlands. Half of the supervisors were female. GP supervisors tend to address the 'poor GP' when prompted to address the 'good GP'. PIF outcomes in GP residency should revolve around taking ownership in patient care, self-care and the persistence of GP as a profession. CONCLUSION: PIF can be challenged by a lack of positive language. Supervisors' strong beliefs regarding ideals of the profession potentially compromise PIF when they do not resonate with residents' beliefs, resulting in poor educational alliance.

Learning in a real-life escape room: an explorative study on the supervisory relationship in GP residency during the COVID-19 pandemic.

BACKGROUND: The relationship between supervisors and residents plays a prominent role in the professional development of general practice (GP) residents. When disruptions occur in the normal course of healthcare, due to effects of e.g. war or emerging epidemics, we need to consider how this may affect the training of the next generation of general practitioners. As both supervisors and residents face new and unprecedented challenges that impact overall quality of the training. In this study, we examined the characteristics of the supervisory relationship in GP training during the disruptions early on during COVID-19. Our aim was to understand better how resident learning is affected in these circumstances, which is a first step in enabling supervisors, residents and faculty to anticipate disruptive situations better in the future. METHODS: We conducted a qualitative case study with a constructivist approach. Seven GP residents at the start of their second placement, and their 10 supervisors participated in this study. Participants came from a University Medical Centre in the Netherlands. Semi-structured interviews were held between September 2020 and February 2021. The subjects were (1) interviewed individually about what they had learned regarding COVID-19, and (2) they were interviewed in supervisory pairs about how they had learned. Data were iteratively analysed; thematic analysis for (1) and template analysis in (2). RESULTS: We identified notable changes in the supervisor-resident relationship attributable to COVID-19. Supervisors and residents were confronted with an all-encompassing uncertainty in the workplace, and disruptive changes in patient care and learning opportunities for residents. Supervisors and residents addressed these emerging workplace challenges through three types of collaboration, (1) getting the job done; (2) residents' learning; and (3) collective learning. Each type had a different focus and distinctive characteristics of the supervisory relationship. CONCLUSION: With the outbreak of COVID-19, supervisors and residents were faced with disruptive uncertainty. In these circumstances, learning occurred not only between residents and their supervisors, but also with non-supervising GPs and assistants in collective learning. We propose to complement collective learning in the workplace with reflection between residents and supervisors at the training institution.

Group Assessment of Resident Performance: Valuable for Program Director Judgment?

BACKGROUND: Group discussion of resident performance is an emerging assessment approach in postgraduate medical education. However, groups do not necessarily make better decisions than individuals. OBJECTIVE: This study examined how group meetings concerning the assessment of residents take place, what information is shared during the meetings, and how this influences program directors' judgment of resident performance. METHODS: In 2017, the researchers observed 10 faculty group meetings where resident performance was discussed and interviewed the program directors within a month after the meetings. We used a thematic framework analysis to identify themes from the transcribed meetings and interviews. RESULTS: The information shared by group members during the meetings had 2 aims: (1) forming a judgment about the residents, and (2) faculty development. Most group members shared information without written notes, most discussions were not structured by the program director, the major focus of discussions was on residents with performance concerns, and there was a lack of a shared mental model of resident performance. The program directors who benefited most from the meetings were those who thought group members were engaged and summarized the information after every discussion. CONCLUSIONS: Unstructured discussions and a lack of a shared mental model among group members impede effective information sharing about resident performance with a developmental approach. Structured discussions with an equal amount of discussion time for every resident and creating a shared mental model about the purpose of the discussions and the assessment approach could enhance use of a developmental approach to assessing resident performance.

The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care.

Phenomenon: Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Approach: Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, n = 5; elderly care, n = 8; family medicine, n = 5; internal medicine, n = 6; orthopedic surgery, n = 6; surgery, n = 6). An iterative grounded theory approach was used to analyze the qualitative data. Findings: Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Insights: Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.

Workplace mentoring of residents in generic competencies by an independent coach.

INTRODUCTION: During postgraduate education in pulmonology, supervisors are responsible for training residents in generic competencies such as communication, professionalism and collaboration, but their focus commonly lies more on medical-technical competencies. As an alternative approach to supporting residents to develop generic skills, we developed a personal mentoring program with a non-medical professional as mentor. In this study, the residents' experiences with the mentoring program were evaluated. METHODS: After an introductory session in which individual learning goals were established, pulmonology residents received at least six, 60-90-minute, individual, mentoring sessions largely consisting of feedback after being observed during daily clinical activities, over a period of 9 months. The residents' experiences with mentoring were explored through in-depth interviews followed by a qualitative content analysis. RESULTS: From March to November 2016, ten residents in pulmonology completed the program. Despite initial scepticism, mentoring encouraged residents to reflect deeply on their professional interactions. This caused an increased awareness of the effects of their communication and behaviour on patients. Experimenting with communication and different behaviours in subsequent interactions felt rewarding and contributed to further development, resulting in increased self-confidence and job satisfaction. DISCUSSION: Mentoring residents by non-medical coaching was associated with improved residents' proficiency in generic competencies.

Efforts, rewards and professional autonomy determine residents' experienced well-being.

The well-being of residents, our future medical specialists, is not only beneficial to the individual physician but also conditional for delivering high-quality patient care. Therefore, the authors further explored how residents experience their own well-being in relation to their professional and personal life. The authors conducted a qualitative study based on a phenomenological approach. From June to October 2013, 13 in-depth interviews were conducted with residents in various training programs using a semi-structured interview guide to explore participants' experience of their well-being in relation to their professional life. The data were collected and analyzed through an iterative process using the thematic network approach. Effort-reward balance and perceived autonomy were dominant overarching experiences in influencing residents' well-being. Experiencing sufficient autonomy was important in residents' roles as caregivers, as learners and in their personal lives. The experienced effort-reward balance could both positively and negatively influence well-being. We found two categories of ways that influence residents' experience of well-being; (1) professional lives: delivering patient care, participating in teamwork, learning at the workplace and dealing with the organization and (2) personal lives: dealing with personal characteristics and balancing work-life. In residents' well-being experiences, the effort-reward balance and perceived autonomy are crucial. Additionally, ways that influence residents' well-being are identified in both their professional and personal lives. These dominant experiences and ways that influence well-being could be key factors for interventions and residency training adaptations for enhancing residents' well-being.

Hospital-wide education committees and high-quality residency training : A qualitative study.

INTRODUCTION: High-quality residency training is of utmost importance for residents to become competent medical specialists. Hospital-wide education committees have been adopted by several healthcare systems to govern postgraduate medical education and to support continuous quality improvement of residency training. To understand the functioning and potential of such committees, this study examined the mechanisms through which hospital-wide education committees strive to enable continuous quality improvement in residency training. METHODS: Focus group studies with a constructivist grounded theory approach were performed between April 2015 and August 2016. A purposeful sample of hospital-wide education committees led to seven focus groups. RESULTS: Hospital-wide education committees strived to enable continuous quality improvement of residency training by the following mechanisms: creating an organization-wide quality culture, an organization-wide quality structure and by collaborating with external stakeholders. However, the committees were first and foremost eager to claim a strategic position within the organization they represent. All identified mechanisms were interdependent and ongoing. DISCUSSION: From a governance perspective, the position of hospital-wide education committees in the Netherlands is uniquely contributing to the call for institutional accountability for the quality of residency training. When implementing hospital-wide education committees, shared responsibility of the committees and the departments that actually provide residency training should be addressed. Although committees vary in the strategies they use to impact continuous quality improvement of residency training, they increasingly have the ability to undertake supporting actions and are working step by step to contribute to high-quality postgraduate medical education.

Teamwork of clinical teachers in postgraduate medical training.

Teamwork among clinical teachers is essential for continuous improvement of postgraduate medical training. This thesis deconstructs teamwork in four studies, mostly based on qualitative research approaches and one study utilizes mixed methods. We found that clinical teachers do train residents, but individually rather than as a team. The programme directors as leaders focus more on teaching activities than on the collective ambition and mutual engagement of clinical teachers. During the teaching meetings, mistakes and conflicts are mainly discussed in a general sense and are often neither directed at the individual, nor result-oriented. A valid evaluation instrument is constructed to improve teamwork.

Evaluating Mind Fitness Training and Its Potential Effects on Surgical Residents' Well-Being: A Mixed Methods Pilot Study.

BACKGROUND: Residents' well-being is essential for both the individual physician and the quality of patient care they deliver. Therefore, it is important to maintain or possibly enhance residents' well-being. We investigated (i) the influence of mind fitness training (MFT) on quality of care-related well-being characteristics: work engagement, empathy, work satisfaction and stress perception and explored (ii) residents' perceptions of MFT. METHODS: A multicenter study was conducted in eight Dutch teaching hospitals, from September 2012 to February 2014, using mixed methods­that is, quantitative and qualitative approaches to data collection and analysis. Eighty-nine surgical residents were invited to participate in pre- and post-intervention questionnaire surveys. Twenty-two residents participated in MFT and were additionally invited to evaluate the training by post-intervention interviews including open questions. RESULTS: At baseline 22 (100%) residents in intervention group and 47 (70.2%) residents in control group, and postintervention 20 (90.9 %) residents in intervention group and 41 (66.1%) residents in control group completed the questionnaires. In intervention-group, residents' specialty satisfaction increased by 0.23 point on 5-point Likert scale (95% CI 0.23­0.24, P < 0.001) while stress scores decreased by -0.94 point on 10-point scale (95% CI -1.77 to -0.12, P = 0.026). No substantial changes were observed in control group. Participation in MFT was positively associated with residents' empathy (b = 7.22; 95% CI 4.33­10.11; P < 0.001) and specialty satisfaction scores (b = 0.42; 95% CI 0.18­0.65; P = 0.001). Residents positively evaluated MFT with median scores of 6.80 for training design and 7.21 for outcome (10-point scale). Residents perceived improvement in focusing skills and reported being more aware of their own state of mind and feeling calmer and more in control. CONCLUSION: Mind fitness training could improve residents' empathy, specialty satisfaction, stress perception, and focusing skills, and was positively received by surgical residents.

Team communication amongst clinical teachers in a formal meeting of post graduate medical training.

The importance of team communication, or more specifically speaking up, for safeguarding quality of patient care is increasingly being endorsed in research findings. However, little is known about speaking up of clinical teachers in postgraduate medical training. In order to determine how clinical teachers demonstrate speaking up in formal teaching team meetings and what factors influence this, the authors carried out an exploratory study based on ethnographic principles. The authors selected 12 teaching teams and observed, audio recorded and analysed the data. Subsequently, during an interview, the program directors reflected on speaking up of those clinical teachers present during the meeting. Finally, the authors analysed iteratively all data, using a template analysis, based on Edmondson's behaviours of speaking up. The study was conducted from October 2013 to July 2014 and ten teams participated. During the teaching team meetings, the clinical teachers exhibited most of the behaviours of speaking up. "Sharing information" strongly resembles providing information and "talking about mistakes" occurs in a general sense and without commitment of improvement activities. "Asking questions" was often displayed by closed questions and at times several questions simultaneously. The authors identified factors that influence speaking up by clinical teachers: relational, cultural, and professional. The clinical teachers exhibit speaking up, but there is only limited awareness to discuss problems or mistakes and the discussion centred mainly on the question of blame. It is important to take into account the factors that influence speaking up, in order to stimulate open communication during the teaching team meetings.

Development and validation of an instrument for measuring the quality of teamwork in teaching teams in postgraduate medical training (TeamQ).

BACKGROUND: Teamwork between clinical teachers is a challenge in postgraduate medical training. Although there are several instruments available for measuring teamwork in health care, none of them are appropriate for teaching teams. The aim of this study is to develop an instrument (TeamQ) for measuring teamwork, to investigate its psychometric properties and to explore how clinical teachers assess their teamwork. METHOD: To select the items to be included in the TeamQ questionnaire, we conducted a content validation in 2011, using a Delphi procedure in which 40 experts were invited. Next, for pilot testing the preliminary tool, 1446 clinical teachers from 116 teaching teams were requested to complete the TeamQ questionnaire. For data analyses we used statistical strategies: principal component analysis, internal consistency reliability coefficient, and the number of evaluations needed to obtain reliable estimates. Lastly, the median TeamQ scores were calculated for teams to explore the levels of teamwork. RESULTS: In total, 31 experts participated in the Delphi study. In total, 114 teams participated in the TeamQ pilot. The median team response was 7 evaluations per team. The principal component analysis revealed 11 factors; 8 were included. The reliability coefficients of the TeamQ scales ranged from 0.75 to 0.93. The generalizability analysis revealed that 5 to 7 evaluations were needed to obtain internal reliability coefficients of 0.70. In terms of teamwork, the clinical teachers scored residents' empowerment as the highest TeamQ scale and feedback culture as the area that would most benefit from improvement. CONCLUSIONS: This study provides initial evidence of the validity of an instrument for measuring teamwork in teaching teams. The high response rates and the low number of evaluations needed for reliably measuring teamwork indicate that TeamQ is feasible for use by teaching teams. Future research could explore the effectiveness of feedback on teamwork in follow up measurements.

Program directors in their role as leaders of teaching teams in residency training.

BACKGROUND: Program directors have a formal leading position within a teaching team. It is not clear how program directors fulfill their leadership role in practice. In this interview study we aim to explore the role of the program director as strategic leader, based on the research-question: What are the experiences of program directors with strategic leadership? METHOD: We conducted an interview study using the principles of phenomenography to explore program directors' experiences. In the period June 2012-May 2013, 16 program directors from different hospital organisations were invited to participate in an interview study. Iterative data collection and analysis were based on strategic leadership: (1) developing collective mindset, (2) focusing on collaborative learning and (3) designing teaching organisation. RESULTS: Fourteen program directors participated in this study. We identified four leadership profiles: (1) captains, (2) carers, (3) professionals and (4) team-players. The 'team-players' come closest to integrally applying strategic leadership. For all four profiles there seems to be a preference for developing collectivity by means of providing information. Program directors have less experience with promoting collaborative learning and the designing of teaching organisation is task-oriented. CONCLUSION: Promoting collaborative learning is the most important challenge for developing leadership within the teaching team.

Explaining how faculty members act upon residents' feedback to improve their teaching performance.

CONTEXT: Responsiveness to feedback is a complex phenomenon that requires and receives attention. However, knowledge on the responsiveness of faculty members to residents' feedback on their teaching performance is lacking. Excellent teaching performance is essential to ensure patient safety and residents' learning in residency training. This study aims to increase our understanding of how faculty staff react to and act upon residents' feedback on their teaching performance. OBJECTIVES: This multi-specialty, multi-institution interview study was conducted to gain insight into: (i) how teaching faculty proceed after they have received residents' feedback on their teaching performance, and (ii) the factors that influence their progression. METHODS: Between August and December 2011, 24 faculty members who had received formative feedback on their teaching performance through valid and reliable feedback systems participated in this study. They reflected upon their (re)action(s) during individual semi-structured interviews. The interview protocol and analysis were guided by a comprehensive transtheoretical framework describing and explaining stages and processes of behavioural change. RESULTS: Faculty staff involved in residency training used residents' feedback to different extents to adapt or improve their teaching performance. Important tipping points in the processes of change necessary for faculty staff to put feedback into practice were: experiencing negative emotions in themselves or recognising those in residents as a result of failure to act upon feedback; realising that something should be done with or without support from others, and making a strong commitment to change. In addition, having the confidence to act upon feedback and recognising the benefits of change were found to stimulate faculty members to change their teaching behaviour. CONCLUSIONS: The responsiveness of faculty members to residents' feedback on their teaching performance varies. The adapted transtheoretical framework explains how and why faculty members do or do not proceed to action after receiving residents' feedback. Given this, organising residents' feedback for faculty staff in a systematic way is a first step and is necessary to effect potential improvements in teaching performance.

Twelve tips for making the best use of feedback.

BACKGROUND: Feedback is generally regarded as crucial for learning. We focus on feedback provided through instruments developed to inform self-assessment and support learners to improve performance. These instruments are being used commonly in medical education, but they are ineffective if the feedback is not well received and put into practice. METHODS: The authors formulated twelve tips to make the best use of feedback based on widely cited publications on feedback. To include recent developments and hands-on experiences in the field of medical education, the authors discussed the tips with their research team consisting of experts in the field of medical education and professional performance, to reach agreement on the most practical strategies. RESULTS: When utilizing feedback for performance improvement, medical students, interns, residents, clinical teachers and practicing physicians could make use of the twelve tips to put feedback into practice. The twelve tips provide strategies to reflect, interact and respond to feedback one receives through (validated) feedback instruments. CONCLUSIONS: Since the goal of those involved in medical education and patient care is to perform at the highest possible level, we offer twelve practical tips for making the best use of feedback in order to support learners of all levels.

Clinical teachers' views on how teaching teams deliver and manage residency training.

BACKGROUND: Residents learn by working in a multidisciplinary context, in different locations, with many clinical teachers. Although clinical teachers are collectively responsible for residency training, little is known about the way teaching teams function. AIM: We conducted a qualitative study to explore clinical teachers' views on how teaching teams deliver residency training. METHOD: Data were collected during six focus group interviews in 2010. RESULTS: The analysis revealed seven teamwork themes: (1) clinical teachers were more passionate about clinical expertise than about knowledge of teaching and teamwork; (2) residents needed to be informed about clinical teachers' shared expectations; (3) the role of the programme director in the teaching team needed further clarification; (4) the main topics of discussion in teaching teams were resident performance and the division of teaching tasks; (5) the structural elements of the organisation of residency training were clear; (6) clinical teachers had difficulty giving and receiving feedback and (7) clinical teachers felt under pressure to be accountable for team performance to external parties. CONCLUSION: The clinical teachers did not consider teamwork to be of any great significance to residency training. Teachers' views of professionalism and their own experiences as residents may explain their non-teamwork directed attitude. Efforts to strengthen teamwork within teaching teams may impact positively on the quality of residency training.