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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
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of specific clinical skills.
165
For example, after initially
doubting that agenda setting is necessary for safe, effective,
patient-centered care, participants see why agenda setting is
beneficial and important after watching a video where the
resident starts the encounter with agenda setting (see Video
5.3).
165
Furthermore, seeing aspirational performance
highlights the value and importance of certain clinical
behaviors that may have initially been dismissed as
unimportant or minimally important.
165
Watching a three-video series emphasizes the importance
of direct observation.
165
Participants often have an “ah ha”
moment when they realize that a resident’s oral case
presentation might be identical after all three video
encounters and not represent what occurred during the
patient visit. As such, FoRT underscores how a learner’s
patient presentation is an incomplete and inadequate proxy
for what occurred during an office visit (in turn impacting
what a patient does after the visit). This realization reinforces
the value of direct observation. Together PDT and FoRT can
increase the quality and specificity of narrative assessment,
although at the expense of increased stringency.
99
Recognizing Inference
As described earlier, during direct observation faculty
frequently and unknowingly make inferences about
learners.
110,111,151
During rater training workshops, workshop
facilitators (and participants) should point out when
inferences are made. When an inference is made, the group
should discuss the behavior that was observed and discuss
the potential explanations for that behavior. The “cause” of
the behavior can then be explored during feedback. For
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example, imagine after watching a video, a faculty member
says, “The resident was uncomfortable addressing the
patient’s substance use.” This is an inference. Whomever
notices the inference should name it as such. The individual
who made the inference should describe what they observed.
For example, perhaps the resident had a halting speech
pattern, started to fidget in their chair, and quickly changed
topics. Rather than assuming the learner was uncomfortable,
these behaviors should be discussed during feedback. During
feedback the preceptor can determine the drivers of the
behaviors (e.g., the resident’s inadequate knowledge about
how to address substance use disorder versus adequate
knowledge about what to ask the patient or concern about
how questions will be received by the patient versus the
resident having a close friend recently hospitalized with
substance use disorder, etc.).
Prioritizing Observations and Creating a
Summary Statement
Given the importance of narrative assessment in competencybased assessment
101–103
and the importance of providing
learners with feedback following direct observation,
105
faculty should learn how to prioritize and synthesize their
observations. After each video, faculty should identify and
discuss which of their observations they would prioritize
during feedback. Prioritized observations should include
what was done well and what could be improved. Prioritized
feedback could focus on (1) skills the learner identified as a
learning goal; (2) skills that were performed exceptionally
well or that are often not seen in an encounter; (3) skills that
are most in need of attention; or (4) skills that would most
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help a future patient receive high-quality care.
While faculty make multiple observations during direct
observation, many observations have a similar theme. It is
helpful, prior to providing feedback, to consider how
individual observations relate to each other. For example,
imagine a learner appropriately recognizes the need to
prescribe a cholesterol-lowering medication but chooses a
statin with an inappropriate potency, fails to mention the
most common side effects, discusses uncommon side effects,
selects an inappropriate dose of the medication, and
recommends the wrong follow-up interval. In addition, the
learner does not address the patient’s hesitance in starting a
medication. While these are six unique observations, they can
be summarized: The resident appropriately identified the patient
qualified for a statin but did not demonstrate adequate knowledge
about prescribing the medication and did not engage the patient in
a shared decision-making conversation. Summary statements do
not need to be shared with the learner but creating one can
help faculty organize and synthesize their observations prior
to feedback. The skill can be practiced by asking several
faculty to share their summary statement after watching and
discussing a training video.
Mitigating Bias
Similar to identifying inference, it is helpful to discuss the
role of bias in assessment and discuss strategies to mitigate
the bias. At a minimum, assessors should do a “bias check”
after making their observations and selecting their rating
(Fig. 5.6
). Additionally, assessors should review their
narrative comments for biased language. Given bias is often
unconscious, program directors and educational systems
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should ensure a programmatic approach to identifying bias
in assessments. While mitigating bias in assessment is
beyond the scope of this chapter, Box 5.3
provides examples
of some strategies that can be used to mitigate bias that are
drawn from the patient communication literature.
166
Box 5.3
Strategies to Mitigate Bias in Assessment
Strategy Description Assessment
example
Stereotype
replacement
Recognizing
when a
stereotype has
been activated,
thinking about
why, and then
actively
substituting
nonstereotypical
thoughts
When writing a
narrative after
direct observation
of a woman
learner, the
assessor stops to
consider if they
may be using
gender-laden
language or uses
an online tool to
assess for gender
bias. If bias is
found, the assessor
substitutes
evidence-based
behavioral skills
that are more
neutral.
Perspective taking Considering
what it would
be like to be a
member of the
minoritized
group
During bedside
rounds faculty
witness a difficult
interaction
between a learner
from a URiM
group with a
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discriminatory
patient. Faculty
should ask
themselves: What
must that be like
for the learner?
How will I
intervene in this
situation?
Individuation Recognizing
when you have
stereotyped
someone
according to
their group
affiliation and
instead
thinking about
what makes
them an
individual
A faculty member
watches a learner
from another
country struggle to
interview a patient
with a possible
sexually
transmitted
disease and
initially
stereotypes the
learner as from a
group
“uncomfortable
talking about sex.”
Instead, the faculty
sees an individual
learner struggling
and seeks to
understand why
they are struggling
as an individual.
Counterstereotypic
imaging
Imagining an
individual or
situation that
counteracts a
stereotypical
reaction in
detail
A faculty member
starts with an
assumption that
women are not
strong enough to
perform
orthopedic
procedures and
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then instead thinks
about successful
women who are
orthopedic
surgeons.
Increased
opportunities for
contact
Increasing
opportunities
for contact with
members of a
stereotyped
group
Programs and
faculty can spend
meaningful time
with URiM
trainees to listen
and learn more
about their lived
experiences and
their path to the
current training
program.
URiM, Underrepresented in medicine.
Opportunities for Additional Practice
As we alluded to earlier, most faculty development occurs as
a single workshop. However, like any skill, improving
observation and feedback requires practice. Therefore
effective faculty development courses have opportunities for
longitudinal practice.
153
There are several options for
longitudinal practice. Faculty can apply their PDT
frameworks to new videos. Ideally practice should include
viewing, assessing, and discussing trigger videos in groups
and comparing narrative assessments and ratings to an
expert. Practice sessions can be brief and can occur either
during a preexisting conference or at a standalone meeting.
Faculty can practice “virtually” through video meetings or
asynchronous online modules. Longitudinal training can also
include PDT and FoRT for new skill domains.
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Repeated practice helps faculty refresh their skills in direct
observation while bringing intervening real-world experience
to practice.
165
Faculty who participate in ongoing practice
describe how it mitigates losing previously acquired skills
and promotes longer-term learning.
165
Practice helps
reinforce the frameworks, thereby building an “internal
model” for the competency being observed.
165
With repeated
practice over time, applying the frameworks starts to become
“second nature.” With time, faculty describe being better able
to identify the more subtle differences in learner skill.
165
FoRT spaced learning also serves as a reminder that learner
presentations are a poor proxy for what a learner does in the
room with a patient.
165
Practicing Skills in Feedback After Direct
Observation
It is beneficial to provide faculty with opportunities to
practice their WBA and feedback skills with live
standardized residents and standardized patients. Since
direct observation is most valuable when it is followed by
feedback, we recommend pairing a rating training workshop
with a workshop on providing effective feedback. This is
then followed by practice giving feedback in which faculty,
in groups of four to six, rotate through four or five different
“stations.” Each station focuses on direct observation of a
different clinical skill (e.g., history taking, physical exam,
counseling, breaking bad news, motivational interviewing,
etc.). A facilitator leads faculty in a brief PDT exercise for that
station (e.g., breaking bad news). The facilitator then
distributes an evidence-based framework for breaking bad
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news.
130
Next, one participant is designated the “preceptor.”
The group watches a standardized resident (trained to
perform the skill at different levels of competence) deliver
bad news to a standardized patient. After the encounter, the
standardized patient and resident step out of the room and
the preceptor discusses their observations and entrustment
rating. The rest of the participants share their observations
and ratings, and the group tries to reach consensus about the
assessment.
The standardized resident (who has been trained to
respond to feedback in different ways) returns to the room
and the preceptor gives them feedback. The other
participants observe the feedback. The preceptor self-assesses
the quality of their feedback; the group then provides the
preceptor with feedback. The standardized resident can also
provide feedback to the preceptor. The standardized
residents frequently have valuable feedback from their
experiences as learners. The session trainer facilitates the
feedback and provides suggestions for improving the
observation and feedback. The activity repeats itself across
the different stations so that each faculty member has a turn
to practice observation and feedback. Each station can focus
on a different skill or on the same skill performed at different
levels. Residents’ responses to feedback can differ across the
stations. We typically start with feedback that is easier to give
(i.e., giving feedback to a resident who is skilled, has insight,
and is receptive to feedback). Subsequent stations are
progressively more difficult (a resident who is unskilled, has
insight, and is receptive to feedback; a resident who is
unskilled, lacks insight, and is not receptive to feedback). The
stations can be recorded so that faculty can review their
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videos at a later point in time.
Faculty describe how one of the most useful components of
rater training is observing standardized residentstandardized patient encounters and providing the
standardized resident with feedback. Practice observing
residents, comparing observations with other faculty,
synthesizing observations into a judgment, and providing
feedback to different “types” of learners is relevant to
faculty’s day-to-day practice. For many faculty, this is the
first time they have been observed giving feedback, and for
most it is the first time they have gotten feedback about their
feedback.
It is helpful to have access to a simulation center and a
standardized patient trainer/coordinator for this activity.
However, if a simulation center is not available, this activity
also can be done with standardized patients and residents in
conference rooms or open rooms in available clinics. Chief
residents and junior faculty are excellent standardized
residents and can easily be trained using tip sheets that
describe varying resident skill levels. Training materials for
faculty development facilitators and standardized residents is
provided in Appendix 5.5 on the Expert Consult website. The
live standardized patient/resident session can be performed
the afternoon of the PDT and FoRT training or can be done
on a separate day.
If there is not access to a simulation center, standardized
residents and/or standardized patients and facilitators can do
a modified version of this activity using videos of a resident
performing a skill (see Appendices 5.2 and 5.6). Faculty
assess the resident in the video and discuss their ratings and
observations as mentioned earlier. Then faculty role-play
feedback. One faculty participant gives feedback to another
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faculty who plays the resident. The individual role-playing
the resident can be given a brief vignette that describes the
resident’s insight and receptivity to feedback (i.e.,
insightful/not insightful; receptive/not receptive). After the
role-play, the group can debrief the feedback as previously
described.
Implementing Workplace-Based
Assessment
Medical student, residency, and fellowship program
directors are responsible for creating or improving systems
for direct observation. This section covers how to implement
direct observation at the programmatic level and how to
think about institutional culture and the educational system
in which direct observation occurs. Successful WBA
implementation requires consideration of work structures
(ensuring sufficient time), organizational culture, instruments
(previously discussed), and users.
147,148
Attention to
implementation strategies can help address WBA enablers
and barriers, leading to more successful uptake of WBA.
167–
169
There are several barriers to direct observation including
lack of faculty buy-in about the importance of direct
observation, perceived or real lack of time for direct
observation, limited comfort doing direct observation, and
concerns about interfering with the learner–patient
relationship. Barriers also include learner buy-in to direct
observation. Finally, there are practical challenges such as
assigning responsibility for direct observations and tracking
observations. For each of these challenges, we offer practical
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