Explicating practice norms and tensions between values in resident training in family medicine
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RESEARCH ARTICLE
Open Access
Explicating practice norms and tensions between values in resident training in family medicine Morhaf Al Achkar
Abstract Background: Residency programs have the intricate and complex role of training health care providers. But little is known about what residents and attendings consider norms of practice or the tensions among different values residents are expected to uphold. Thus, dialogical and reflective frameworks are being explored for resident learning. Methods: This study examined the use of facilitated conversations with groups of residents and attending physicians while reviewing video-recorded resident–patient interactions. The conversations were recorded, transcribed, and qualitatively analyzed. Results: A total of 24 residents and 10 attendings participated in conversations while separately and in parallel groups reviewing 15 resident sessions. Residents explicated the norms of practice and evaluated their performance, which often agreed with those of attending physicians in calling out important learning opportunities. When disagreement occurred, residents’ explications of their reasoning were often relevant and, via reflection and dialogue, helped clarify intentions that were not apparent in the videos. Residents and attendings often judged actions on more than one domain of value. For instance, if a resident addressed problems, built relationships in a timely manner, and acted autonomously without jeopardizing the quality of care, she satisfactorily performed her duty. Conclusions: Practice norms and value struggles were addressed by participants during reviews, which provided a promising framework for learning and assessment. Also, the non-hierarchical structure opened space to acknowledge a diversity of positions and for tensions among values to be explicated. Keywords: Reflective practice, Video-reviews, Peer-learning, Resident education
Background The complex role of training doctors is ascribed to residency programs, which must support resident learning while still providing safe patient care. Residencies grapple with strategies that can simultaneously uphold the two ends [1–6]. An increasing body of evidence supports the premise that resident engagement in reflection and self-assessment improves learning [7–11]. There is also evidence that learning from peers may be equal to or more effective than learning from an attending [12]. Furthermore, many viable learning Correspondence: [email protected] Department of Family Medicine, University of Washington, Seattle, WA, USA
models exist that center on learners, with non-hierarchical engagement and empowerment of participants [13–17]. In contrast, learning has historically been viewed as adaptation, where the learner performs a behavior, then an evaluator gives feedback, and finally, the learner performs again [7, 8, 18]. In this style of assessment, an evaluator observes an object and judges its behavior. Variations exist around who is performing the evaluation (e.g., attending, peer, self) and who is giving the feedb
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