What affects you? A conversation analysis of exploring emotions during reflection sessions in Dutch general practitioner training.

Introduction: In Dutch training for general practitioners (GPs), reflection on professional practice is key to their training. Such reflection is considered beneficial for professional development, especially when it entails discussing the emotional dimension of practice experiences. In the GP context, invitations to share the emotional side of things, such as "how did that make you feel?" are considered functional; yet, they are also sometimes viewed by participants as 'grilling', 'just too much' or 'too intimate'. Put shortly, putting emotions on the table is institutionally embedded in the GP reflection context, but not always straightforward. Thus, we ask: 'how do teachers and GP residents invite talk about emotions in educational reflection sessions?'. Methods: In this study, we explored the Dutch phrase 'raken, geraakt worden' (being affected) as one interactional practice used to initiate emotion talk. We conducted a conversation analytic collection study of instances of this phenomenon based on 40 video recordings of hour-long 'reflection sessions' at the Dutch GP specialty training. During these sessions, approximately ten GPs in training discuss recent experiences from medical practice under supervision of one or two teachers. Results: We found that participants orientated to the relevance of 'being affected' as a topic for discussion. Variations of the form 'what affects you now?' may contribute to putting emotions on the table; they can project a stepwise exploration of the emotional dimension of an experience. The 'what affects you now', often done in interrogative format doing a noticing, in combination with a request, is a powerful tool to instigate transformative sequences. The form is less effective to put emotions on the table when the topic shift it initiates is not grounded in previously presented personal stakes or displayed emotion. Discussion: The study's findings show how detailed interactional analysis of one sequentially structured practice can benefit education and contribute to theory on emotions and reflection. The mobilizing power of 'what affects you' can serve institutional purposes by doing topical work in relation to educational aims, while its power can also be deflated when prior talk does not project the relevance of unpacking the emotional dimension of an experience. Its interactional workings may translate to other helping contexts as well.

When and how teachers intervene in group discussions on experiences from practice in postgraduate medical education: an interactional analysis.

Medical educators constantly make decisions on when and how to intervene. Current literature provides general suggestions about types of teacher interventions. Our study aims to specify that knowledge by describing in detail the actions teachers do when intervening, the interactional consequences of those actions, and how these relate to teacher roles in group discussions. We collected all first teacher interventions (n = 142) in 41 videorecorded group discussions on experiences from practice at the Dutch postgraduate training for General Practice. We analyzed the interventions using Conversation Analysis. First, we described the timing, manner, actions, and interactional consequences of each intervention. Next, we inductively categorized actions into types of actions. Finally, we analyzed the distribution of these types of actions over the group discussion phases (telling, exploration, discussion, conclusion). First teacher interventions were done at observably critical moments. Actions done by these interventions could be categorized as moderating, expert, and evaluating actions. Moderating actions, commonly done during the telling and exploration phase, are least directive. Expert and evaluator actions, more common in the discussion phase, are normative and thus more directive. The placement and form of the actions done by teachers, as well as their accounts for doing those, may hint at a teacher orientation to intervene as late as possible. Since the interventions are occasioned by prior interaction and responded to in different ways by residents, they are a collaborative interactional accomplishment. Our detailed description of how, when and with what effect teachers intervene provides authentic material for teacher training.

A professional knowledge base for collaborative reflection education: a qualitative description of teacher goals and strategies.

INTRODUCTION: For several decades, educational experts have promoted reflection as essential to professional development. In the medical setting, collaborative reflection has gained significant importance across the curriculum. Collaborative reflection has a unique edge over individual reflection, but many medical teachers find facilitating group reflection sessions challenging and there is little documentation about the didactics of teaching in such collaborative reflection settings. To address this knowledge gap, we aim to capture the professional knowledge base for facilitating collaborative reflection by analyzing the formal and perceived goals and strategies of this practice. METHODS: The professional knowledge base consists of formal curricular materials as well as individual teacher expertise. Using Template Analysis, we analyzed the goals and strategies of collaborative reflection reported in institutional training documents and video-stimulated interviews with individual teachers across all Dutch general practitioner training institutes. RESULTS: The analysis resulted in a highly diverse overview of educational goals for residents during the sessions, teacher goals that contribute to those educational goals, and a myriad of situation-specific teacher strategies to accomplish both types of goals. Teachers reported that the main educational goal was for residents to learn and develop and that the teachers' main goal was to facilitate learning and development by ensuring everyone's participation in reflection. Key teacher strategies to that end were to manage participation, to ensure a safe learning environment, and to create conditions for learning. DISCUSSION: The variety of strategies and goals that constitute the professional knowledge base for facilitating collaborative reflection in postgraduate medical education shows how diverse and situation-dependent such facilitation can be. Our analysis identifies a repertoire of tools that both novice and experienced teachers can use to develop their professional skill in facilitating collaborative reflection.

A participant perspective on collaborative reflection: video-stimulated interviews show what residents value and why.

The potential of reflection for learning and development is broadly accepted across the medical curriculum. Our understanding of how exactly reflection yields its educational promise, however, is limited to broad hints at the relation between reflection and learning. Yet, such understanding is essential to the (re)design of reflection education for learning and development. In this qualitative study, we used participants' video-stimulated comments on actual practice to identify features that do or do not make collaborative reflection valuable to participants. In doing so, we focus on aspects of the interactional process that constitute the educational activity of reflection. To identify valuable and less valuable features of collaborative reflection, we conducted one-on-one video-stimulated interviews with Dutch general practice residents about collaborative reflection sessions in their training program. Residents were invited to comment on any aspect of the session that they did or did not value. We synthesized all positively and negatively valued features and associated explanations put forward in residents' narratives into shared normative orientations about collaborative reflection: what are the shared norms that residents display in telling about positive and negative experiences with collaborative reflection? These normative orientations display residents' views on the aim of collaborative reflection (educational value for all) and the norms that allegedly contribute to realizing this aim (inclusivity and diversity, safety, and efficiency). These norms are also reflected in specific educational activities that ostensibly contribute to educational value. As such, the current synthesis of normative orientations displayed in residents' narratives about valuable and less valuable elements of collaborative reflection deepen our understanding of reflection and its supposed connection with educational outcomes. Moreover, the current empirical endeavor illustrates the value of video-stimulated interviews as a tool to value features of educational processes for future educational enhancements.

Beyond the Medical Model: Thinking Differently about Medical Education and Medical Education Research.

Issue: In medical education, teaching is currently viewed as an intervention that causes learning. The task of medical education research is seen as establishing which educational interventions produce the desired learning outcomes. This 'medical model' of education does not do justice to the dynamics of education as an open, semiotic, recursive system rather than a closed, causal system. Evidence: Empirical 'evidence' of 'what works' - that is, what is supposed to affect 'learning' - has become the norm for medical educational improvements, where generalized summary outcomes of research are often presented as must-follow guidelines for myriad future educational situations. Such investigations of educational processes tend to lack an explicit engagement with the purposes of medical education, which we suggest to understand in terms of qualification (the acquisition of knowledge, skills, and understanding), socialization (becoming a member of the professional group) and subjectification (becoming a thoughtful, independent, responsible professional). In addition, investigations of educational processes tend to rely on causal assumptions that are inadequate for capturing the dynamics of educational communication and interaction. Although we see an increasing acknowledgement of the context-dependency of teaching practices toward educational aims, the currently prevailing view in medical education and educational research limits understanding of what is actually going on when educators teach and students participate in medical education - a situation which seriously hinders advancements in the field. Implications: In this paper, we hope to inform discussion about the practice of medical education by proposing to view medical education in terms of three domains of purpose (professional qualification, professional socialization, and professional subjectification) and with full acknowledgement of the dynamics of educational interaction and communication. Such a view implies that curriculum design, pedagogy, assessment, and evaluation should be reoriented to include and integrate all three purposes in educational practice. It also means that medical education research findings cannot be applied in just any teaching context without carefully considering the value of the suggested courses of actions toward the particular educational aims and teaching setting. In addition, medical educational research would need to investigate all three purposes and recognize the openness, semiotic nature, and recursivity of education in offering implications for teaching practice.

What motivates general practitioners to change practice behaviour? A qualitative study of audit and feedback group sessions in Dutch general practice.

OBJECTIVES: Adopting an attributional perspective, the current article investigates how audit and feedback group sessions contribute to general practitioners' (GPs) motivation to change their practice behaviour to improve care. We focus on the contributions of the audit and feedback itself (content) and the group discussion (process). METHODS: Four focus groups, comprising a total of 39 participating Dutch GPs, discussed and compared audit and feedback of their practices. The focus groups were analysed thematically. RESULTS: Audit and feedback contributed to GPs' motivation to change in two ways: by raising awareness about aspects of their current care practice and by providing indications of the possible impact of change. For these contributions to play out, the audit and feedback should be reliable and valid, specific, recent and recurrent and concern GPs' own practices or practices within their own influence sphere. Care behaviour attributed to external, uncontrollable or unstable causes would not induce change. The added value of the group is twofold as well: group discussion contributed to GPs' motivation to change by providing a frame of reference and by affording insights that participants would not have been able to achieve on their own. CONCLUSIONS: In audit and feedback group sessions, both audit and feedback information and group discussion can valuably contribute to GPs' motivation to change care practice behaviour. Peer interaction can positively contribute to explore alternative practices and avenues for improvement. Local or regional peer meetings would be beneficial in facilitating reflection and discussion. An important avenue for future studies is to explore the contribution of audit and feedback and small-group discussion to actual practice change.

Using conversation analysis to explore feedback on resident performance.

Feedback on clinical performance of residents is seen as a fundamental element in postgraduate medical education. Although literature on feedback in medical education is abundant, many supervisors struggle with providing this feedback and residents experience feedback as insufficiently constructive. With a detailed analysis of real-world feedback conversations, this study aims to contribute to the current literature by deepening the understanding of how feedback on residents' performance is provided, and to formulate recommendations for improvement of feedback practice. Eight evaluation meetings between program directors and residents were recorded in 2015-2016. These meetings were analyzed using conversation analysis. This is an ethno-methodological approach that uses a data-driven, iterative procedure to uncover interactional patterns that structure naturally occurring, spoken interaction. Feedback in our data took two forms: feedback as a unidirectional activity and feedback as a dialogic activity. The unidirectional feedback activities prevailed over the dialogic activities. The two different formats elicit different types of resident responses and have different implications for the progress of the interaction. Both feedback formats concerned positive as well as negative feedback and both were often mitigated by the participants. Unidirectional feedback and mitigating or downplaying feedback is at odds with the aim of feedback in medical education. Dialogic feedback avoids the pitfall of a program director-dominated conversation and gives residents the opportunity to take ownership of their strengths and weaknesses, which increases chances to change resident behavior. On the basis of linguistic analysis of our real-life data we suggest implications for feedback conversations.