In this week’s iteration of KeyLIME, Linda discusses How Attending Physicians Negotiate Their Work Environment – “to generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment,” as well as how evidence from observing attending physicians in the workplace links to a competency-based framework (CanMEDS competencies / Roles).
KeyLIME Session 155:
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Article 1) Bacchus M, Ward DR, de Grood J, Lemaire JB. How evidence from observing attending physicians links to a competency-based framework Med Educ. 2017 Jun; 51(6):633-644. Article 2) Lemaire JB, Wallace JE, Sargious PM, Bacchus M, Zarnke K, Ward DR, Ghali WA. How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography. Acad Med. 2017 Jun 20. [Epub ahead of print]
Reviewer: Linda Snell (@LindaSMedEd)
Internal medicine inpatient teaching units are a prime setting for students and resident learning. The ward attending (preceptor) plays a central role – cares for ill patients, teaches learners of various skill levels, leads multidisciplinary teams, role modeling, etc.
However, there’s little empirical evidence to guide them in this task – just a lot of ‘How to’ guides and ‘tips’ but little direct observation of tasks of an attending beyond teaching, or of the integration of these activities in the workplace.
With the change to CBME there is also little evidence to show whether our current attending physicians enact the competencies they are teaching or express all the competencies in a competency framework. Many learners feel that not all competencies are well modelled by all attendings.
Today we will look at two papers that use parts of the same data-set to answer 2 questions:
1. How Attending Physicians Negotiate Their Work Environment – “to generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment.”
2. How evidence from observing attending physicians in the workplace links to a competency-based framework (CanMEDS competencies / Roles).
Type of Paper
Key Points on Methods
Data collection used collective ethnography – 2 sets of observers: ‘insiders’ (other institutions’ experienced attendings) and ‘outsiders’ (social scientists). Observations ~ 3h of attendings at work on the ward, field notes and impressions written; data from both groups analyzed separately using an inductive thematic analysis, then in a symposium looked at both together.
For study 2 each subtheme was mapped to a CanMEDS competency, then competencies ‘back mapped’ to themes.
123 components – 14 themes – 3 major elements of the preceptor role were identified:
(1) Competence or the execution of traditional physician competencies or professional skills,
(2) Context or the medical teaching unit environment where the attending works,
(3) Conduct or the manner of acting or behaviors and attitudes (e.g preceptors’ use of adaptive behaviors and attitudes such as creativity, interpersonal skills, and wellness behaviors, that help negotiate the environment)
Multiple connections between the elements emerged.
(2) Many subthemes mapped to CanMEDS 2005 and 2015.
Many role-related components from the Competence element, some from Conduct element and none from the Context element were represented in the 2015 CanMEDS framework.
The authors concludes: ’Preceptors not only possess traditional competencies, but also enlist additional behaviors and attitudes to deal with context-driven tensions and to negotiate their complex work environment. These skills could be incorporated into role training, orientation, and mentorship.’
‘the real-world work of attending physicians links to the CanMEDS framework but identifies disconnects between espoused and observed behaviours, in which, in particular, competencies that help mitigate the influence of the context are not well represented in a medical education framework.’
Spare Keys – other take home points for Clinician Educator
Implications of study 1 for us is the link of the individual and the context or system, and the need to train not only for traditional, but new competencies, and also to evaluate attendings on what they actually do.
Supports the concept of EPAs.
This research team has been effective at using data to explore multiple questions.
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