The Resident Learning Journey in the Medical Intensive Care Unit.

Background: The medical intensive care unit (MICU) offers rich resident learning opportunities, but traditional teaching strategies can be difficult to employ in this fast-paced, high-acuity environment. Resident perspectives of learning within this environment may improve our understanding of the common challenges residents face and inform novel approaches to transform the MICU educational experience. Objective: We conducted a qualitative study of internal medicine residents to better understand their approach to learning the critical care activities that they are entrusted to perform in the MICU. Methods: Using a thematic analysis approach, we conducted six focus group interviews with 15 internal medicine residents, separated by postgraduate year. A trained investigator led each interview, which was audio-recorded and transcribed verbatim for analysis. Our diverse research team, representing different career stages across the continuum of learning to minimize interpretive bias, identified codes and subsequent themes inductively. We refined these themes through group discussion and sensitizing social learning theory concepts using Wenger's community of practice and organized them to create learner archetypes and a conceptual framework of resident learning in the MICU. Results: We identified three thematic resident learning categories: learning goals and motivation, clinical engagement, and interprofessional collaboration. We distinguished three learner archetypes, the novice, experiential learner, and practicing member, to describe progressive resident development within the interprofessional MICU team, the challenges they frequently encounter, and potential teaching strategies to facilitate learning. Conclusion: We developed a conceptual framework that describes the resident's journey to becoming a trusted, collaborating member of the interprofessional MICU team. We identified common developmental challenges residents face and offer educational strategies that may support their progress. These findings should inform future efforts to develop novel teaching strategies to promote resident learning in the MICU.

Professional identity struggle and ideology: A qualitative study of residents' experiences.

INTRODUCTION: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. METHODS: We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. RESULTS: We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. CONCLUSION: This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study.

BACKGROUND: Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). OBJECTIVE: The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. DESIGN: The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. PARTICIPANTS: The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. APPROACH: The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. KEY RESULTS: GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. CONCLUSIONS: IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

Fitting In While Standing Out: Professional Identity Formation, Imposter Syndrome, and Burnout in Early-Career Faculty Physicians.

PURPOSE: Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition. METHOD: The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data. RESULTS: Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF. CONCLUSIONS: Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.

STOPS: A Coping Framework for Surgeons Who Experience Intraoperative Error.

OBJECTIVE: To investigate the steps faculty surgeons take upon experiencing intraoperative error and synthesize these actions to offer a framework for coping with errors. BACKGROUND: While intraoperative errors are inevitable, formal training in error recovery is insufficient and there are no established curricula that teach surgeons how to deal with the intraoperative error. This is problematic because insufficient error recovery is detrimental to both patient outcomes and surgeon psychological well-being. METHODS: We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with faculty surgeons from 3 hospitals. Surgeons described recent experiences with intraoperative error. Interviews were transcribed and coded. Analysis allowed for development of themes regarding responses to errors and coping strategies. RESULTS: Twenty-seven surgeons (30% female) participated. Upon completion of the analysis, themes emerged in 3 distinct areas: (1) Exigency, or a need for training surgical learners how to cope with intraoperative errors, (2) Learning, or how faculty surgeons themselves learned to cope with intraoperative errors, and (3) Responses, or how surgeons now handle intraoperative errors. The latter category was organized into the STOPS framework: Intraoperative errors could produce STOPS: Stop, Talk to your Team, Obtain Help, Plan, Succeed. CONCLUSIONS AND RELEVANCE: This study provides both novel insight into how surgeons cope with intraoperative errors and a framework that may be of great use to trainees and faculty alike.

Reframing professional identity through navigating tensions during residency: A qualitative study.

INTRODUCTION: Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training. METHODS: Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data. RESULTS: Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training. DISCUSSION: The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities.

The Effect of Bedside Rounds on Learning Outcomes in Medical Education: A Systematic Review.

PURPOSE: To determine if bedside rounds, compared with other forms of hospital ward rounds, improve learning outcomes in medical education. METHOD: For this systematic review, the authors searched Ovid MEDLINE, Embase, and Scopus from inception through February 20, 2020. Experimental studies were included if they (1) compared bedside rounds to any other form of rounds in a hospital-based setting, and (2) reported a quantitative comparison of a learning outcome (e.g., learner reaction, knowledge, skills, behavior, health care delivery) among physicians-in-training (medical students, residents, fellows). Extraction elements were summarized using descriptive statistics and a narrative synthesis of design, implementation, and outcomes. RESULTS: Twenty studies met inclusion criteria, including 7 randomized trials. All studies involved resident physicians, and 11 also involved medical students. The design and implementation of bedside rounds varied widely, with most studies (n = 13) involving cointerventions (e.g., staff education, real-time order entry).Of the 15 studies that reported learner satisfaction, 7 favored bedside rounds, 4 favored the control, and 4 were equivocal. Of the 4 studies reporting an outcome of learners' knowledge and skills, 2 favored bedside rounds and 2 were equivocal. Of the 8 studies that reported on learner behavior (e.g., bedside communication with patients), 5 favored bedside rounds, 1 favored the control, and 2 were equivocal. Finally, of the 14 studies that reported a health care delivery outcome (e.g., teamwork, rounding time), 8 favored bedside rounds and 6 were equivocal. Due to the high risk of bias and unexplained heterogeneity across studies, the overall strength of evidence was low. CONCLUSIONS: In hospital-based settings, learners' satisfaction with bedside rounds is mixed. However, bedside rounds appear to have a positive effect on learner behavior and health care delivery. Given their potential value, additional research is needed to identify barriers to and facilitators of educationally successful bedside rounds.

Autonomy and developing physicians: Reimagining supervision using self-determination theory.

In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.

Resident impression management within feedback conversations: A qualitative study.

INTRODUCTION: Medical education is moving to conceptualise feedback as a bidirectional learning conversation. Within this conversation, learners experience a tension between assessment and feedback. That perceived tension affects learners' outward performances. In this study, we aimed to characterise residents' experiences with this tension and its effect on learner authenticity within feedback conversations. METHODS: In this constructivist grounded theory study, the authors were informed by Goffman's theory of impression management. During data analysis, Dweck's theory of mindset was adopted. The authors conducted semi-structured interviews with 15 internal medicine residents. Data collection and analysis were conducted iteratively, using constant comparison to identify themes coinciding with impression management and mindset, ultimately developing a theoretical model to help explain residents' responses to tensions within feedback conversations. RESULTS: Residents constantly felt 'scrutinized', and this affected their engagement in feedback conversations. They staged a performance within those conversations, linked to their underlying mindset: growth or fixed. Growth mindset was characterised by a focus on development as a physician and was associated with asking questions and seeking opportunities for growth. Fixed mindset was characterised by a focus on achieving a favourable evaluation and was associated with a hesitation to ask questions when faced with uncertainty and admit opportunities for growth, because they were concerned about impression management. Context influenced mindset and impression management. Residents adopted a fixed mindset and managed impressions when they perceived the permanence or consequences of evaluations within feedback. Residents adopted a growth mindset when they trusted the supervisor. DISCUSSION: Residents assess the context of feedback conversations, altering the authenticity of their behaviours. Context, including the perceptions of formal assessment and relationships with supervisors, affected residents' mindset and impression management. Providing space for relationship-building and clarifying the purpose and structure of assessment may be helpful in supporting effective learning conversations in graduate medical education.

The relationship between learner engagement and teaching effectiveness: a novel assessment of student engagement in continuing medical education.

BACKGROUND: Continuing medical education (CME) often uses passive educational models including lectures. However, numerous studies have questioned the effectiveness of these less engaging educational strategies. Studies outside of CME suggest that engaged learning is associated with improved educational outcomes. However, measuring participants' engagement can be challenging. We developed and determined the validity evidence for a novel instrument to assess learner engagement in CME. METHODS: We conducted a cross-sectional validation study at a large, didactic-style CME conference. Content validity evidence was established through review of literature and previously published engagement scales and conceptual frameworks on engagement, along with an iterative process involving experts in the field, to develop an eight-item Learner Engagement Instrument (LEI). Response process validity was established by vetting LEI items on item clarity and perceived meaning prior to implementation, as well as using a well-developed online platform with clear instructions. Internal structure validity evidence was based on factor analysis and calculating internal consistency reliability. Relations to other variables validity evidence was determined by examining associations between LEI and previously validated CME Teaching Effectiveness (CMETE) instrument scores. Following each presentation, all participants were invited to complete the LEI and the CMETE. RESULTS: 51 out of 206 participants completed the LEI and CMETE (response rate 25%) Correlations between the LEI and the CMETE overall scores were strong (r = 0.80). Internal consistency reliability for the LEI was excellent (Cronbach's alpha = 0.96). To support validity to internal structure, a factor analysis was performed and revealed a two dimensional instrument consisting of internal and external engagement domains. The internal consistency reliabilities were 0.96 for the internal engagement domain and 0.95 for the external engagement domain. CONCLUSION: Engagement, as measured by the LEI, is strongly related to teaching effectiveness. The LEI is supported by robust validity evidence including content, response process, internal structure, and relations to other variables. Given the relationship between learner engagement and teaching effectiveness, identifying more engaging and interactive methods for teaching in CME is recommended.

Characteristics of Effective Teachers of Invasive Bedside Procedures: A Multi-institutional Qualitative Study.

BACKGROUND: Faculty supervision of invasive bedside procedures (IBPs) in the ICU may enhance procedural education and ensure patient safety. However, there is limited research on teaching effectiveness in the ICU, and there are no best teaching practices regarding the supervision of IBPs. RESEARCH QUESTION: We conducted a multi-institutional qualitative study of pulmonary and critical care medicine faculty and fellows to better understand characteristics of effective IBP teachers. STUDY DESIGN AND METHODS: Separate focus groups (FGs) were conducted with fellows and faculty at four large academic institutions that were geographically distributed across the United States. FGs were facilitated by a trained investigator, audio-recorded, and transcribed verbatim for analysis. Themes were identified inductively and compared with constructs from social and situated learning theories. Data were analyzed between and across professional groups. Qualitative research software (NVivo; QSR International) was used to facilitate data organization and create an audit trail of the analysis. A multidisciplinary research team was engaged to minimize interpretive bias. RESULTS: Thirty-three faculty and 30 fellows participated. Inductive analysis revealed three categories of themes among successful IBP teachers: traits, behaviors, and context. Traits included calm demeanor, trust, procedural competence, and effective communication. Behaviors included leading preprocedure huddles to assess learners' experiences and define expectations; debriefing to provide feedback; and allowing appropriate autonomy. Context included learning climate, levels of distraction, patient acuity, and institutional culture. INTERPRETATION: We identified specific traits and behaviors of effective IBP teachers that intersect with the practice environment, which highlights the challenge of teaching IBPs. Notably, FG participants emphasized interpersonal, more than technical, aspects of successful IBP teachers. These findings should inform future curricula on teaching IBPs in the ICU, standardize IBP teaching for pulmonary and critical care medicine fellows, and reduce patient injury from procedural complications.

Autonomy and professional identity formation in residency training: A qualitative study.

CONTEXT: Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training. METHODS: Using constructivist grounded theory, we conducted 23 semi-structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de-identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data. RESULTS: Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making 'real decisions' for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care. CONCLUSIONS: This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.

Characteristics and quality of rotation-specific resident learning goals: a prospective study.

Background: Residents are expected to develop the skills to set learning goals. Setting learning goals is part of self-regulated learning, setting the foundation for creating a learning plan, deploying learning strategies, and assessing their progress to those goals. While effective goal setting is essential to resident self-regulated learning, residents struggle with setting learning goals and desire faculty assistance with goal setting.Objective: We aimed to characterize the topics and quality of residents' rotation-specific learning goals.Design: We conducted a prospective study of 153 internal medicine residents, assessing 455 learning goals for general medicine inpatient rotations. We coded learning goal themes, competencies, and learning domains, and assessed quality using the validated Learning Goal Scoring Rubric. We compared topic categories, competencies, learning domains, and quality between the first and second months of postgraduate (PGY)-1 residents and between PGY-1 and PGY-3 residents. We assessed factors associated with learning goal completion.Results: The overall response rate was 80%. The top three learning goal categories were patient management, specific diseases related to general medicine, and teaching skills. There were no changes in learning goal characteristics between PGY-1 months (p ≥ 0.04). There were differences between PGY-1 and PGY-3 residents' learning goals in patient management (28% vs 6%; p < .001), specific disease conditions (19% vs 3%; p < .001), and teaching skills (2% vs 56%; p < .001). There was no difference in learning goal quality between PGY-1 months (1.63 vs. 1.67; p = 0.82). The PGY-3 learning goals were of higher quality than PGY-1 learning goals for the 'specific goal' item (1.38 vs. 0.98, p = 0.005), but not for other items or overall (all p ≥ 0.02). Residents reported 85% (297/347) learning goal completion.Conclusions: Resident rotation-specific learning goals reflect a broad array of topics. Residents' learning goal quality was low and residents may benefit from guidance to support residents' learning goals.

Coaching Versus Competency to Facilitate Professional Identity Formation.

Professional identity formation, with its focus on the development of professional values, actions, and aspirations, is the ideal goal of medical education. Medicine is a community of practice, and medical education is a socialization process by which novice trainees become full community members. The authors believe coaching provides an ideal means for promoting this socialization process to develop a learner's identity as they engage in the community. Coaching involves an orientation toward growth and development, valuing reflection and nurturing continuous reflection, and embracing failure as an opportunity for learning. However, there are challenges to implementing coaching in medical education. Competency-based medical education has provided clear outcomes (competencies) for medical education and programs of assessment around these competencies. Yet, there is a tension in medical training between professional identity formation (the process of socialization into the profession) and the formal assessment process. The ideal of multiple low-stakes assessments and written evaluations, intended as formative assessments, are perceived by residents as high-stakes evaluations with significant consequences for their future. The authors present a resident story that highlights this tension. They outline Goffman's theory of impression management, postulating that medicine's assessment system encourages residents to stage a performance for evaluators that displays their competence and conceals their perceived weaknesses. This performance hinders coaching and the formation of an appropriate professional identity. Coaching, the authors believe, provides a model that aligns assessment and professional identity formation. Given the challenges to implementing coaching in medical education, the authors propose several questions to contemplate when integrating coaching into medical education to facilitate the goal of professional identity formation.