Patient-present teaching in the clinic: Effect on agency and professional behaviour.

BACKGROUND/PURPOSE: Although much has been written about the medical learning environment, the patient, who is the focus of care, is rarely the focus in this literature. The purpose of this study was to explore the role of the patient as an active participant with agency in the medical learning environment from the standpoint of the learner, the attending physician, and most importantly, the patient. We hoped to gain insights into the mechanisms that can reinforce professional values such as patient-centred and respectful behaviours in a patient-present learning environment. METHODS: We conducted this study in an ambulatory internal medicine clinic using 'patient-present' clinic visits. All case presentations occurred in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semistructured interviews after each clinic visit to explore the impact of the patient-present learning environment. We recruited 34 participants in the study; 10 attending physicians, 12 learners, 10 patients and 2 family members. We analysed the data deductively using a conceptual framework of agency. SUMMARY/RESULTS: We identified three major insights: (1) Patients felt engaged and valued opportunities to be heard; (2) Attending physicians and learners reported a more respectful learning environment and a positive though challenging teaching and learning experience; and (3) A hidden curriculum emerged in a performance-based view of professional behaviour. CONCLUSIONS: Patient-present teaching engaged patients and enhanced their agency by recasting the patient as the central focus within the healthcare encounter. We identified a tension between performing and learning. This study adds new insights to the concept of patient centredness and professionalism from the perspectives of all participants in the medical teaching and learning environment.

Incentives for clinical teachers: On why their complex influences should lead us to proceed with caution.

INTRODUCTION: When medical education programs have difficulties recruiting or retaining clinical teachers, they often introduce incentives to help improve motivation. Previous research, however, has shown incentives can unfortunately have unintended consequences. When and why that is the case in the context of incentivizing clinical teachers remains unclear. The purposes of this study, therefore, were to understand what values and motivations influence teaching decisions; and to delve deeper into how teaching incentives have been perceived. METHODS: An interpretive description methodology was used to improve understanding of the development and delivery of teaching incentives. A purposeful sampling strategy identified a heterogenous sample of clinical faculty teaching in undergraduate and postgraduate contexts. Sixteen semi-structured interviews were conducted and transcripts were analyzed using an iterative process to develop a thematic structure that accounts for general trends and individual variations. RESULTS: Clinicians articulated interrelated and dynamic personal and environmental factors that had linear, dual-edged and inverted U-shaped impacts on their motivations towards teaching. Barriers were frequently rationalized away, but cumulative barriers often led to teaching attrition. Clinical teachers were motivated when they felt valued and connected to their learners, peers, leadership, and/or the medical education community. While incentives aimed at producing these connections could be perceived as supportive, they could also negatively impact motivation if they were impersonal, inequitable, inefficient, or poorly framed. DISCUSSION/CONCLUSION: These findings reinforce the literature suggesting that it is necessary to proceed with caution when labeling any particular factor as a motivator or barrier to teaching. They take us deeper, however, towards understanding how and why clinical teachers' perceptions are unique, dynamic and fluid. Incentive schemes can be beneficial for teacher recruitment and retention, but must be designed with nuance that takes into account what makes clinicians feel valued if the strategy is to do more good than harm.

The disconnect between knowing and doing in health professions education and practice.

Safe and effective healthcare requires that new knowledge or skills, once learned, are incorporated into professional practice. However, this process is not always straightforward. Learning takes place in complex contexts, requiring practitioners to overcome various motivational, systemic, emotional, and social barriers to the application of knowledge. This paper explores the mechanisms through which individuals translate knowledge into action to provide insight into why disconnects between knowledge and action can arise. As a critical review, the aim was to draw on key literature from multiple fields to analyse and synthesize existing schools of thought and lay a strong conceptual foundation on which knowledge to action gaps might be considered. We iteratively consulted clinicians and experts in various fields to guide literature searches focused on theoretical perspectives that could inform educational and research efforts around knowledge-to-action gaps. Key theoretical perspectives on motivation address when and how individuals decide to take action. Literatures from cognitive science address how clinicians and learners self-regulate to (sometimes) overcome barriers to action. Sociocultural theories examine the ways in which action might be prevented by social norms that conflict with what the individual knows and believes, potentially also giving rise to counter-normative action. No single perspective will entirely explain how health professionals and learners implement knowledge in practice. As a result, the authors offer multiple lenses through which to view the problem, and then propose how each of these lenses might better guide educational and research efforts to untangle this challenging but important issue.

Incentivizing Medical Teachers: Exploring the Role of Incentives in Influencing Motivations.

PURPOSE: Medical education is dependent on clinicians and other faculty who volunteer time and expertise to teaching. Unfortunately, the literature reports increasing levels of dissatisfaction, burnout, and attrition. Incentivization provides an obvious intervention, but rewards must be implemented judiciously or risk unintended consequences. With little known about the effects of incentives in medical education, the authors investigate key insights across three disciplines to explain how, why, and when incentives can be used effectively. METHOD: In this critical synthesis, a purposeful and iterative literature search was conducted by exploring a variety of databases to identify seminal articles, key concepts, and generative search terms. Particularly fruitful disciplines were then explored more deliberately. RESULTS: Psychologists argue that the impact of an incentive depends on an individual's motivational drives. Organizational behaviorists draw attention to environmental incentives and disincentives that build or detract from motivation. Behavioral economists posit that size, type, and way in which an incentive is provided affect motivation differently. CONCLUSIONS: The influence of an incentive depends on how it interacts with underlying mechanisms deemed important for motivation. These mechanisms change across tasks, individuals, and contexts. Recommendations derived from the effort include being deliberate about (1) determining what is driving the individual to act, (2) considering the unique interactions between incentives and motivation types, and (3) considering barriers that may interfere with incentive effectiveness. In examining each of these, the authors argue that the field needs greater clarity regarding how, when, and why incentives operate within the many contexts in which medical educators work.

Residents' views of the role of classroom-based learning in graduate medical education through the lens of academic half days.

PURPOSE: To examine the role of classroom-based learning in graduate medical education through the lens of academic half days (AHDs) by exploring residents' perceptions of AHDs' purpose and relevance and the effectiveness of teaching and learning in AHDs. METHOD: The authors invited a total of 186 residents in three programs (internal medicine, orthopedic surgery, and hematology) at the University of British Columbia Faculty of Medicine to participate in semistructured focus groups from October 2010 to February 2011. Verbatim transcripts of the interviews underwent inductive analysis. RESULTS: Twenty-seven residents across the three programs volunteered to participate. Two major findings emerged. Purpose and relevance of AHDs: Residents believed that AHDs are primarily for knowledge acquisition and should complement clinical learning. Classroom learning facilitated consolidation of clinical experiences with expert clinical reasoning. Social aspects of AHDs were highly valued as an important secondary purpose. Perceived effectiveness of teaching and learning: Case-based teaching engaged residents in critical thinking; active learning was valued. Knowledge retention was considered suboptimal. Perspectives on the concept of AHDs as "protected time" varied in the three programs. CONCLUSIONS: Findings suggest that (1) engagement in classroom learning occurs through participation in clinically oriented discussions that highlight expert reasoning processes; (2) formal classroom teaching, which focuses on knowledge acquisition, can enhance informal learning occurring during clinical activity; and (3) social aspects of AHDs, including their role in creating communities of practice in residency programs and in professional identity formation, are an important, underappreciated asset for residency programs.