#KeyLIMEpodcast 145: Do they practice what you preach?

Renting N, Raat ANJ, Dornan T, Wenger-Trayner E, van der Wal MA, Borleffs JCC, Gans ROB, Jaarsma ADC. Integrated and implicit: how residents learn CanMEDS roles by participating in practice. Med Educ. 2017 May 9. [Epub ahead of print]

Reviewers: Linda Snell (@LindaSMedEd)

Background

Almost all postgraduate (residency) training programs apply a competency framework to structure curriculum, teaching, learning and assessment, with the CanMEDS framework being one of the most frequently used. However, most of resident competence is acquired in the workplace through supervised patient care, and assessed through multiple formative and summative methods. Many of the CanMEDS Roles are thought be acquired best, if not only, through work-based learning, often in a tacit manner.

Clinical activities are followed by ‘interpretation’ and ‘construction of meaning’ (reflection?) where interactions with supervisors are important.

Social learning theory, particularly Communities of practice (CoP) suggest that the practice itself, rather than an outside definition of competence, has the most influence. Thus how the Roles are adopted, expressed, enacted in practice would be of prime importance.

Prior studies have shown that:

-assessment instruments often are unable to distinguish between the Roles and fail to achieve a balanced representation of the competency framework.

– supervisors may have different, complex conceptions of competence than those described in competency frameworks:

– supervisors defined CanMEDS roles more by personal experiences and beliefs than  how they are described on paper

–  supervisors have a holistic view of competence, in which individual CanMEDS roles cannot be distinguished and view residents’ competence as complex and not a ‘simple linear addition’ of performance .

Purpose

“…to explore how the CanMEDS framework informs residents’ practice-based training and interactions with supervisors.”

Type of Paper

Research: grounded theory analysis of observations and interviews, ethnographic approach

Key Points on Methods

Used a sociocultural perspective, especially CoP, to provide ‘sensitizing insights’ for constructivist grounded theory methodology.

Very nice description of qualitative methodology, all steps included (design, context, team, recruitment, data collection and analysis).

• Internal medicine departments of 3 Dutch hospitals, where CanMEDS in a foundation for residency training
• Varied research team brought specific experiences and expertise
• Purposive recruitment to maximize variance
• Data collected from
  • direct observation of residents on duty in their wards, emergency rooms and out-patient clinics, using structured field notes
  • brief field interviews
  • in depth formal interviews
• inductive analysis, open and axial coding, relationship of themes

Key Outcomes

12 resident, 14 supervisors, varied backgrounds; 136 hours of observation.

Three aspects:

1. CanMEDS and residents’ activities: residents typically combined aspects of multiple CanMEDS roles in their clinical activities. The leader role was usually identified but not acted on.
2. CanMEDS and interactions: interactions with peers and supervisors helped residents define what they had learned from their work. These did not explicitly reflect CanMEDS, but generally aligned well with the attitudes and behaviors expressed in the Roles. The names of CanMEDS roles were rarely mentioned either in teaching or between supervisors. (not part of shared language)
3. CanMEDS and organizational structure: e.g. schedules, EMRs, sign-over documents, dictated conversations more than roles did.

Theoretical discussion – CanMEDS did not provide a shared language; roles sometimes seemed to represent descriptions of roles within an ideal world, which did not align well with the reality of clinical practice.

Suggestions for better integration provided

Key Conclusions

The authors conclude that ‘a competency framework such as CanMEDS seems to be only one of many artefacts that influence how residents learn in a community of practice. Although many supervisory interactions reflected CanMEDS, the framework does not appear to guide supervisors or residents. It is therefore questionable whether the implementation of CanMEDS-based training has caused a shift in practice, or whether the CanMEDS framework simply fitted a practice that was already changing in that direction. Although CanMEDS may be an appropriate tool for the assessment of residents’ professional performance, it seems less useful to guide comprehensive practice-based training.

Spare Keys – other take home points for clinician educators

This paper provides a nice description of their qualitative methodology

Shout out

Dutch colleagues who have been using CanMEDS

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