Systems-Based Practice Learning Opportunities in Student-Run Clinics: A Qualitative Analysis of Student Experiences (Acad Med, 2013)
Leslie Sheu, MD, Bridget O’Brien, PhD, Patricia S. O’Sullivan, EdD, Austin Kwong, and Cindy J. Lai, MD
Dr. Sheu is a first-year internal medicine resident and former student-run clinic volunteer and coordinator, University of California, San Francisco, School of Medicine, San Francisco, California.
Dr. O’Brien is assistant professor, Department of Medicine and Office of Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California.
Dr. O’Sullivan is professor and director, Office of Medical Education, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
Mr. Kwong is a former volunteer at a student-run clinic at the University of California, San Francisco, San Francisco, California.
Dr. Lai is associate professor and faculty advisor for a student-run clinic elective, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
Correspondence should be addressed to Dr. Sheu, University of California, San Francisco, Department of Medicine, 533 Parnassus Ave., Box 0131, San Francisco, CA 94143; telephone: (415) 476-1964; fax: (415) 502-7544; e-mail: leslie.sheu@ucsf.edu.
Method
Participants and setting
The University of California, San Francisco (UCSF), School of Medicine has four independently run SRCs that provide care for underserved populations (for an overview of the clinics, see Table 1). Each year, approximately 70% (n = 105) of the school’s first-year medical students serve as volunteers who participate directly in patient care (with some students volunteering at more than one SRC), and 25% (n = 40) of first-year students become coordinators, assuming a leadership role with responsibilities for organizing and running the clinics. Coordinators continue in their positions during their second year of medical school, and many students continue to volunteer in their second year. At three of the four SRCs, interprofessional students from pharmacy, nursing, and/ or dental schools also provide patient care and act as coordinators.
Study design
As our study was exploratory in nature, we conducted in-depth, semistructured interviews with medical students who were or had been involved with the SRCs and with SRC faculty advisors. Using the interview guide we developed, one of us (L.S.) conducted pilot interviews with four former SRC coordinators. On the basis of these interviews, we modified the guide to improve the flow of the questions, but we did not change the content. We asked all student interviewees to provide basic demographic information, describe the different roles of students participating in the SRCs, discuss the opportunities they had to learn about SBP through their SRC participation and formal curricular experiences, and reflect on their overall SRC experience. We used the same guide for the faculty interviews, but we asked faculty advisors to describe students’ SBP learning opportunities. (Our interview guide is available as Supplemental Digital Appendix 1 at http://links.lww.com/ ACADMED/A129.)
Between November 2011 and February 2012, we recruited and interviewed former SRC volunteers or coordinators (medical students in their third or later year), current SRC volunteers or coordinators (second-year medical students), and SRC faculty advisors who had been in their roles for several years at the time of our study. Including these three groups gave us a range of perspectives and allowed for triangulation of themes to increase validity of our results.20
After the pilot interviews, we recruited additional participants using a combination of purposive and snowball sampling techniques.21 One of us (L.S.) contacted 21 current and former coordinators using information available online and interviewed the first 2 to 3 responders from each SRC for a total of 14 (2 current and 1–2 former coordinators per SRC, including the 4 pilot interviewees). We targeted this number of coordinators, anticipating saturation of ideas, and found this to be the case. L.S. asked the participating coordinators to recommend volunteers to interview and invited 14 past and current volunteers to participate. She interviewed the first current and past volunteer who responded per SRC. She stopped conducting volunteer interviews following these 8, after hearing similar ideas with no new responses.
After completing the student interviews, L.S. interviewed one of the primary faculty advisors for each SRC. These faculty were familiar with and responsible for overseeing the clinics’ activities.
Analysis
We analyzed the interview transcripts using thematic analysis.22 Prior to analysis, we agreed to broadly define SBP as “how patient care relates to the health care system as a whole and how to use the system to improve the quality and safety of patient care.”12 We also agreed to frame our coding to explore the four key elements of SBP outlined by Meah and colleagues19: “interdisciplinary and team-based care,” “resource acquisition and allocation,” “advocacy and navigation of the health care system to overcome barriers,” and “quality care.” Three of us (L.S., B.C.O., C.L.) read the same two coordinator transcripts independently to develop initial coding categories. At this stage, we modified Meah and colleagues’ four domains and added two other domains. In addition, we created codes for capturing students’ comparisons of SBP learning opportunities in SRCs to content in the formal curriculum, as well as comparisons of volunteer and coordinator experiences.
Once we finalized our coding cate- gories, three of us (L.S., B.C.O., C.L.) independently coded one transcript and reviewed discrepancies to clarify the definition of each code. Two of us (L.S., C. L.) each coded the remainder independently and discussed any disagreements until we reached con- sensus. We then coded the faculty interviews and used those data to check for similarities and differences between faculty and student perspectives.
We used NVivo version 8 (QSR International, Melbourne, Australia) to organize data for thematic analysis. We reviewed all the content coded in each category to identify themes and representative examples.
All potential interviewees were contacted by e-mail. The recruitment e-mails assured them that their responses would be confidential. Interviews were conducted in person or over the telephone, depending on interviewee preference and availability. All interviews were audio-recorded and deidentified by L.S. They were transcribed by L.S. and A.K. This study was approved by the UCSF Committee on Human Research.
22 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.
ACADMED_88_6_2013_03_04_SHEU_203337_SDC1.pdf
Medical students’ perceptions and attitudes about family practice: a qualitative research synthesis (BMC Med Educ, 2012)
Anna Selva Olid1, Amando Martín Zurro2,3*, Josep Jiménez Villa2,3,4, Antonio Monreal Hijar5, Xavier Mundet Tuduri4, Ángel Otero Puime6, Gemma Mas Dalmau7 and Pablo Alonso-Coello 7 for the Universidad y Medicina de Familia Research Group (UNIMEDFAM)
* Correspondence: a.martinzurro@gencat.cat
2Servicio Catalán de la Salud, División de Planificación y Evaluación Operativa, Barcelona, Spain
3Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Gran Via 587 àtic, 08007, Barcelona, Spain
Full list of author information is available at the end of the article
Methods
A systematic review and synthesis of qualitative studies using a thematic synthesis approach was conducted [13].
Analytical approach
The selected studies were thoroughly read. The type of study, its methodology, how information was collected and what type of analysis was performed for each study was identified. The authors of the studies were con- tacted to confirm witch methodology and type of ana- lysis was used (Table 1). Key themes and sub-themes were identified. The process of theme searching was dy- namic and it did not finish until all the studies were accounted for. Emerging theme definitions and limits were discussed for their development and refinement. A descriptive chart was created for each study including key information such as: author, date, country, method- ology, results, quality and limitations (Additional file 2). The initial list of themes was used to create a matrix, derived from an approach described by Miles and Huberman [15], allowing the comparison of each theme across the studies. This matrix was reviewed and refined and the themes were grouped until it was pos- sible to synthesize all the studies.
Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India (BMC Med Educ, 2016)
Susanne Sjöström1,2*, Birgitta Essén2, Kristina Gemzell-Danielsson1 and Marie Klingberg-Allvin1,2,3
* Correspondence: susanne.sjostrom@ki.se
1Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
2Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden Full list of author information is available at the end of the article
Method
Study design
We used a qualitative design conducting in-depth inter- views with twenty-three medical students in Maharastra applying a topic guide. Data was organized using the- matic analysis with an inductive approach.
Setting
Maharashtra is India’s second most populous state with 112 million inhabitants, and the third largest by area. The state capital Mumbai is the largest city in India with around 13.3 million inhabitants, yet a slight majority of the state’s inhabitants live in rural areas. In 2010–2012 the maternal mortality rate in Maharastra of 178 was around half of the national average, and according to data from 2001–2003 the maternal mortality due to abortion was 3 % for a group of seven well-off states in- cluding Maharastra [33]. Child sex ratio (0–6 years) was 883 females per 1000 males (national average 914) in the 2011 census, and the gender gap increased in the decade 2001–2011 [5, 34]. There are 44 medical colleges offering the MBBS degree to 5945 students in Maharas- tra of which 19 are run by the government [34].
Study participants
In-depth interviews were conducted with 23 medical students in their last year of training leading to the MBBS degree (internship). The students attended 6 different col- leges (4 government (n =15) and 2 private (n =8)) in urban and peri-urban areas. The schools were purposively sampled among 28 private and public colleges that had previously engaged in a survey on attitudes to abortion. Purposive sampling was conducted with the aim to create maximum-variation representation within the group, e.g. to include participants with different socio-geographical- cultural backgrounds respecting gender, age, religion, marital status, and place of upbringing. A key-informant, the head of department at each college facilitated identifi- cation of eligible students, who were invited to participate. All included participants were between 22 and 25 years old. Thirteen respondents were men and ten were women, none were currently in a relationship. Most confessed to Hinduism, three were Buddhists, one Christian and one Muslim. A few had been sexually active. Oral and written information was given about the study, and participation was voluntary and anonymous. All interviews were con- ducted in privacy.
Data collection
A topic guide with open-ended questions and probes was developed to explore students’ attitudes and percep- tions toward abortion and provision thereof, medical abortion, and task shifting in comprehensive abortion care. The interview guide was subject to constant revi- sion as information from one interviewee influenced the interviewer’s knowledge of the subject [35, 36].
The first author, a Swedish Obstetrician-Gynaecologist who had been residing in India for two and a half years at the time of the study, conducted the interviews in English, the language of tuition at the included colleges. The interviews were conducted in three batches with two larger cities covered during December 2012, one city visited February 2013 and two smaller cities and a peri-urban area in April 2013. The interviews were tape- recorded and lasted between 30 min to one hour. Field notes were taken. Between interviews initial analysis and development of interview guides and probes was con- ducted. Interviews were continued until theoretical saturation was reached.
Data analysis
The data was analysed using an inductive thematic ap- proach applying a realist framework to report the experi- ence, meaning and reality of the participants [37]. The recorded data was transcribed verbatim, the transcripts were read through and the recordings repeatedly listened to by the first author. Data was coded manually and or- ganized into units of analysis with a semantic, explicit, approach to identify patterns and themes. The first au- thor conducted the coding and initial analysis; subse- quently data and results were reviewed and evaluated by all authors.
37. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.
Educating change agents: a qualitative descriptive study of graduates of a Master’s program in evidence-based practice (BMC Med Educ, 2016)
Grete Oline Hole1*, Sissel Johansson Brenna1, Birgitte Graverholt1, Donna Ciliska1,2 and Monica Wammen Nortvedt1
* Correspondence: Grete.Oline.Hole@hib.no
1Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
Methods
To examine the graduates experiences a qualitative descriptive design was chosen [13, 14]. Within the prag- matic framework [15] focus group interviews were conducted to capture participants’ collective discussion and reflection, following Krueger and Casey’s guidance [16]. This included planning the study, development and refinement of the interview-guide (“the question route” ([16], p 41), moderating each interview, with use of appropriate “pauses and probes” ([16], p 99), using an iterative process of analyses, and interpreting data and presenting findings.
Setting
Master’s programs in Norway are equivalent to two years full-time study, credited with 60 European Credit Transfer and Accumulation System (ECTS) credits each year [17]. A multi-professional Master’s program in evidence-based practice (MA-EBP) has been offered at Bergen University College, Norway since 2008. An overall aim of the programis to educate consumers of research who are able to initiate and carry out improvements in health care.
Sample and data collection
This study was conducted with the first two graduating cohorts (30 people). The graduates were mainly health care professionals but health librarians and health jour- nalists were also represented. All had considerable work experience, and many had earned postgraduate educa- tion (Table 2). While enrolled in the program, students worked part-time and their work experience was essen- tial for fulfilling some of the learning tasks.
Invitations were sent by e-mail one year after gradu- ation. Out of 30 potential participants, 22 volunteered, 11 from each cohort. Six semi-structured focus groups discussions with 3–4 participants in each were conducted. One participant who could not attend the focus group was interviewed by telephone.
The discussions were audiotaped and memos were written during the focus groups to capture the con- text. GOH and SJB facilitated and co-facilitated the interviews, except for one group in the second cohort where GOH had been supervising these students. In this case SJB moderated the discussion with another co-moderator.
The focus groups/interview lasted between 60–120 min. All professions represented in the cohorts partici- pated in the focus groups and all participants were female. Each participant had a unique identifier, by the cohort (2008 or 2009), the sequence of the interviews (1–4) and by the number of the participants (1–4).
Data analysis
The more than 12 h of taped discussion were transcribed to 130 pages of text by a research assistant. Interim analysis guided the planning of the next focus groups.
A thematic analysis was done with each transcript with the four themes for the semi-structured interview guide as starting point [24]. This focused upon experiences as students, perceptions of their competencies in EBP, role performance in EBP and suggestions for improvements in the educational program (not included in this paper as the purpose was feedback to the program). The analysis involved carefully reading through the transcript several times, first to get an overview over the interview and then to group the statements into the initial themes. When the three first interviews were grouped, a further rereading and grouping took place. The statements were then condensed and tentative codes and subcodes were developed for each group session. Thereafter the coded statements from the first cohort were pulled together for each initial theme. Next, statements were further grouped and condensed to new codes, where one sought to identify patterns and clarify what seemed to be essential for the students. Matrices were used to get an overview and make comparisons [25]. Saturation was not a goal of the analysis, as all potential participants were invited there was no possibility of increasing the number of participants.
The analysis was undertaken by GOH, but at each central step in the process the preliminary findings was discussed with SJB. Each session involved dialogue over the codes and how tentative findings could be inter- preted. Reflection notes were written before and after the meetings. Each step followed the criteria by Lincoln and Guba to ensure trustworthiness and authenticity [26]. Findings from the first cohort guided the interviews and analysis with the second cohort. For the second cohort, we sought to explore more in-depth how the students experienced the intended link between the model of EBP (Fig. 1), the study program and the under- lying pedagogical framework. Did the program promote the defined learning outcomes? Did it give participants the necessary competencies to implement EBP in their clinical practice? Minor adjustment of the interview guide and the introductory question were made at this point. Students’ experiences were still discussed, but with a closer focus on their feedback regarding the program rather than their personal experiences. For each theme we explored their experiences as adult learners, tasks rooted in cognitive learning theories linked to- wards lifelong learning and their thoughts about using EBP in the future. The coding first followed the same procedure as for cohort 1. Thereafter the findings from all seven data collection sessions were pulled together and further in-depth analysis was conducted with a closer focus upon the participants learning outcomes. Other authors (BG, DC and MWN) participated in analysis, discussion of the presentation of the findings and refinement of the model.
13. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23:334–40. doi:10.1002/1098-240X(200008)23:4<334:: AID-NUR9>3.0.CO;2-G.
14 Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs 14. Health. 2010;33:77–84. doi.org/10.1002/nur.20362.
24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101. doi.org/10.1191/1478088706qp063oa.
Informal teacher communities enhancing the professional development of medical teachers: a qualitative study (BMC Med Educ, 2016)
Thea van Lankveld1,2*, Judith Schoonenboom1, Rashmi Kusurkar2, Jos Beishuizen1, Gerda Croiset2
and Monique Volman3
* Correspondence: t.van.lankveld@vu.nl
1Faculty of Behavioural and Movement Sciences, LEARN!, VU University Amsterdam, Amsterdam, Netherlands
2VUmc School of Medical Sciences Amsterdam, LEARN!, Amsterdam, Netherlands
Methods
Design
In order to study the processes involved in teacher communities, we employed a qualitative approach. The processes were observed. In order to understand how the participants had experienced the processes, semi- structured interviews were conducted with the tutors.
Setting
The teacher communities
Participants
About 30 tutors from both clinical and non-clinical de- partments were invited to participate in the communi- ties by e-mail. Nineteen accepted the invitation: ten tutors from year 1 and nine tutors from year 2. Most of these tutors did not know each other prior to the teacher community. All participants in the teacher com- munities were invited to voluntarily participate in the interviews. Ten agreed (four tutors from the first year of the bachelor’s programme and six tutors from the sec- ond year), while nine declined because of time con- straints. Demographic details regarding the participants are presented in Table 2.
Data collection
During the first semester, TvL took detailed observation notes during and immediately after the meetings of the two communities. As the processes we were looking for were unknown beforehand, we did not use a standar- dised observation scheme. Instead, we tried to include anything that seemed relevant to the research question from the perspective of the theoretical framework. The notes were qualitative in nature. They included: the con- tent of the discussion, i.e. the questions brought in (domain) and the solutions offered (practice) and any side discussions, and the interactions between the members and any important events or incidents (community).
After the semester, TvL held individual semi-structured interviews with the participants.
TvL is a female educationalist holding an MSc in Psychology and extensive experience in qualitative methods. The participants were aware of the aim of the interview, namely to reflect on the personal outcomes of the teacher communities (both positive and negative) and on the processes within the teacher communities that had contributed to these outcomes. The interview schedule was developed by TvL and MV and is available online as Additional file 1. Questions were asked about being a tutor (domain), as well as in what ways the teacher community had contributed to their understand- ing of the tutor role (practice) and to contacts with other tutors (community). We also added two questions in which the participants were encouraged to explicate any negative experiences or things they had missed in the teacher community. The interview schedule was adapted after the first interview (the data of which has not been included in the analysis).
The interviews lasted for 60–90 min and took place at the university, without anyone else being present apart from the interviewer and the interviewee. Field notes were made during the interview. The interviews them- selves were audiotaped and transcribed verbatim. Sum- maries of the interviews were sent to the participants for member checking.
Analysis
Data analysis was performed from an interpretivist point of view [29], which fits well with our aim to construct insightful accounts of the processes involved in the teacher communities. First, TvL and JS analysed the ob- servation notes. Through repeated reading of the obser- vation notes and extended discussions concerning our interpretations, we identified two main processes in the teacher communities, which were derived from the data. In order to gain further understanding of the way the participants had experienced those processes, we ana- lysed the interview data using thematic analysis [30]. We started with the two initial processes that we had identi- fied in the observation notes as initial themes, but allowed for additional themes to emerge. The data was first systematically and iteratively analysed in Atlas.ti by TvL, and then re-analysed by JS. Any discrepancies were discussed until consensus was reached, which led to the further refinement of the analysis. In order to adequately interpret the interview data, we repeatedly went back over the original observation notes, so as to relate the participants’ accounts of the processes and their effects on them to the processes we had observed. The product of the analysis, a detailed description of three processes including illustrative data extracts and relevant context- ual information, was discussed with the whole research team (i.e. triangulation of investigators [31]).
Reflection on the role of the researchers
TvL played a double role due to both serving as a co- facilitator in the teacher communities and being in- volved in the data collection and analysis. She was therefore not a neutral observer, but was involved in the teacher communities herself. We acknowledge that this might have influenced the findings and our account of them. At the same time, we experienced that this double role actually helped us to understand the participants’ responses during the interviews, and it also helped us to recognise and understand the processes involved in the teacher communities during the analysis. To minimise possible conflicts between the two roles, a second researcher was involved in the data analysis, which assisted TvL in creating dis- tance from her role as co-facilitator. Additionally, the research team, consisting of two scientists from the medical education field and three educational scien- tists, functioned as a critical review board during the data analysis.
Additional file 1: Interview schedule. (DOCX 18 kb)
29. Bunniss S, Kelly DR. Research paradigms in medical education research. Med Educ. 2010;44:358–66.
30. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psych. 2006;3:77–101.
* Correspondence: davorina.petek@gmail.com
1Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Poljanski nasip 58, Ljubljana 1000, Slovenia
Methods
Participants
Regional coordinators
Family medicine trainees
Progress of the study
Analysis
All audiotapes were transcribed verbatim and checked for accuracy. The transcript was analysed using thematic analysis, which contains analysis of raw data by open coding, category formation and abstraction [7, 8] by the so-called inductive technique from text level.
The unit of analysis was defined, (a transcript of one focus group) and the unit of coding (raw data as blocks of quotations). Codes were assigned to the quotations. Three independent researchers coded the text (D.P., Z.K.K., B.P.) and in case of differences, discussed the analysis until an agreement was reached. In the second stage, duplicated codes and codes which were not relevant to the research question were reduced to a final list of codes. Conse- quently, the codes were grouped by their similarities into themes. Themes and codes of regional coordinators and specialist trainees were compared to each other. The last stage represented Interpretation of the analysis and was made by associating the text and the context of the codes and themes. Codes were assigned by appropriate quota- tions and interpreted in the context of the text.
7. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008; 62:107–15.
Exploring challenges in implementing a health systems science curriculum: a qualitative analysis of student perceptions (Med Educ, 2016)
Jed D Gonzalo,1 Paul Haidet,1 Barbara Blatt2 & Daniel R Wolpaw1
1Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
2Office of Medical Education, Penn State College of Medicine, Hershey, Pennsylvania, USA
Correspondence: Jed Gonzalo, Division of General Internal Medicine, Penn State Hershey Medical Center – HO34, 500 University Drive, Hershey, Pennsylvania 17033, USA. Tel: 1 717 531 8161; E-mail: jgonzalo@hmc.psu.edu
METHODS
Study approach
Because there is very little in the literature in the way of student attitudes to systems-based educational curricula, we used a data-driven inductive approach for our study.19–22 We used a qualitative thematic analysis with several grounded-theory analytical tech- niques appropriate for the exploratory nature of the research question. We chose focus group interviews rather than surveys or individual interviews because we wanted to explore students’ perceptions in detail, while also providing a safe environment for interaction and potential agreement and disagree- ment among participants. The Institutional Review Board determined this project to be minimal-risk research.
Study setting
In 2013, the Penn State College of Medicine (PSCOM) received a grant fromthe American Medi- cal Association to implement a new systems naviga- tion curriculum, with the primary goal of aligning medical education with health systemneeds.23 This new curriculumwas to include two key components.7
First, a new health systems course was designed, last- ing 17 months with an estimated 125 contact hours, focusing on topics such as insurance, cost, care coor- dination, population and public health, health care performance and value, teamwork and leadership.6,7
Second, to foster motivation and relevance to the new classroom-based course, students were to be embedded into health systems in south-central Penn- sylvania as patient navigators. Patient navigation is an intervention that uses outreach workers to explore patients’ barriers to care and helps themnavigate complex health care systems to obtain the required care and reduce disparities.24,25
Participant sampling
Because we expected students at different stages in their education to perhaps have different viewpoints about HSS, we intentionally recruited medical stu- dents from each of the four years (MS1–4) of Penn State’s curriculum in order to obtain a sample that included the varying levels of experience. We sent e-mails describing the study and requesting inter- ested students to sign up for a pre-scheduled inter- view. Focus groups were comprised of three to seven participants, with each group including mem- bers of the same class. None of the students in the study had experienced any part of the new curricu- lum described above.
Data collection
Two experienced facilitators with knowledge of medi- cal education but without leadership positions in the medical school moderated and digitally recorded the focus-group discussions. We used an interview guide (see Appendix S1) that was informed by the relevant literature on SBP, experiential workplace-based learn- ing and curriculum design.12,13,16,18,26,27 As demon- strated in the interview guide, our questions were designed to encourage and probe responses about HSS in general, rather than issues specific to our local environment alone.
We began each discussion by ask- ing participants to write down their understanding of the meaning of the term‘systems-based practice’. Following this activity, the discussion focused on stu- dents’ understanding of SBP concepts, their percep- tions of the importance of such concepts in a medical school curriculum, issues surrounding experiential systems-based education and participation as patient navigators, and how they prioritised different learn- ing subjects during medical school. A professional transcriptionist prepared a verbatimtranscript of each audio-recorded focus-group session.
Data analysis
Members of our research team with experience in qualitative research led the analysis phase of our study. Our research team’s perspective in approach- ing this work was that HSS has value in the training of medical students and in 21st-century medical practice. As such, we were particularly careful to ensure focus group moderators worded their ques- tions and probes neutrally, and we performed an informal analysis of the questions and probes asked to ensure the moderator was not asking leading questions that implied that students should value this content. In addition, we performed several cross-checks, described below, to ensure that our results could be confirmed.
We approached our data using thematic analysis with several grounded-theory analytical tech- niques.22,28,29 We used Atlas.tiTM 6.0 (Scientific Soft- ware, Berlin, Germany) software to manage the text data. During each focus-group session, the modera- tor recorded notes to inform the initial codebook. We reviewed these notes as well as the focus group transcripts using a process of constant comparative analysis to identify initial themes and categories and generate a preliminary codebook.19,20 Because we were unsure if data saturation would be reached across all four years of training, we made an a priori decision to complete all scheduled focus groups regardless of whether saturation was reached at an earlier point.
One investigator (JG) independently analysed an initial transcript and modified the code- book. Through regular adjudication sessions with a co-investigator (BB), initial codes were compared for inconsistency and agreement, followed by updat- ing of the codebook. Members of the research team individually reviewed transcripts and cross-checked the text with the developed codebook, which informed subsequent adjudication sessions. The team discussed disagreements and collapsed and modified codes as necessary. Finally, the research team discussed overarching categories, themes and exemplar quotations, and developed a conceptual framework to explain students’ perspectives regard- ing systems-based education.
DISCUSSION
Why isn’t educational change happening more quickly and meaningfully in the area of health care systems, and why do schools appear ‘immune’ to change? In their seminal work on immunity to change, Kegan and Lahey outline a conceptual framework for understanding both why it is difficult to make changes and what can be done about it.40 They suggest a personal or organisational ‘X-ray’ designed to uncover the inner-workings of difficul- ties with change. Best intentions (such as the com- mitment to teach HSS) are often accompanied by actions or inactions that do not support this goal (things being done or not done instead, such as preparing students for successful residency applica- tions), which can be mapped to faculty staff and education leadership worries (such as fears that stu- dents will not be matched with their preferred resi- dency positions) and underlying assumptions (e.g. criteria for a residency cannot be changed or other criteria for assessing competence are not as impor- tant or accurate as the USMLE). Such underlying assumptions are often not acknowledged and serve as powerful forces maintaining the status quo. Once such assumptions are identified, strategies to test the assumptions can be implemented to begin to move the previously immovable ‘object’. In the con- text of our results, we recognise the need to re- establish ownership and control of the core mission of medical education. Although standardised tests can measure a fund of knowledge, they represent only a small fraction of the overall learning and professional development outcomes that medical schools should be (and would like to be) promoting for their students. Many educators are aware of this, and our results suggest students are as well. In Table 1, we subjected the challenge identified by students (i.e. competing educational agendas) to the Kegan/Lahey X-ray. Although this represents a specific example, we feel that this model has the potential for broad applicability as medical educa- tors seek to change what has previously been consid- ered unchangeable. It provides a focus and a guide for identifying and challenging key underlying assumptions that may be preventing us from achiev- ing our goals for future physicians and the health care system. The change is long overdue. We believe the Kegan/Lahey framework provides an identifi- able starting point and direction that can be applied in multiple settings.
Table 1 Immunity to change X-ray relating to health systems science in undergraduate medical education (from the perspective of faculty members and the education leadership)
19 Bernard HR, Ryan GW. Analyzing Qualitative Data: System- atic Approaches. Los Angeles, CA: Sage 2010; xxi, 451 pp.
20 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;2 (3):77–101.
40 Kegan R, Lahey LL. Immunity to Change: How to Overcome it and Unlock Potential in Yourself and Your Organization. Boston, MA: Harvard Business Press 2009; xvii, 340 pp.
ThematicAnalysis MedEduc Gonzalo_et_al-2016-Medical_Education medu12957-sup-0001-AppendixS1.docx
The “Handling” of power in the physician patient encounter: perceptions from experienced physicians (BMC Med Educ, 2016)
Laura Nimmon1,2* and Terese Stenfors-Hayes3
* Correspondence: laura.nimmon@ubc.ca
1Centre for Health Education Scholarship, Vancouver, Canada
2Department of Occupational Science and Occupational Therapy, 429 – 2194 Health Sciences Mall, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
Methods
Research design
This current research was part of a larger study that ex- plored how physicians conceptualise their teaching and consultation practices and their thoughts about their professional development in these roles. For this current study we wanted to understand how physicians perceive power relations in the physician-patient encounter. To achieve this, 30 physicians were interviewed and the transcribed data analysed using an inductive thematic approach further described below.
Population, sample and data collection
We used purposeful sampling to capture a wide range of physicians to ensure we could fully understand the topic under study. The co-investigators on the larger study represented one of the five disciplines, and thus identi- fied colleagues that fit the study’s inclusion criteria of having at least five years of experience in teaching pa- tients and trainees. An email introductory letter that de- scribed the larger study was sent to all colleagues identified by the study’s co-investigators. Approximately 4 (70 %) out of 6 (100 %) of those physicians initially contacted in each discipline were interested in partici- pating, and were subsequently sent a consent form prior to the interview taking place. To recruit the additional two participants we used a snowball sampling technique which involved asking those interviewed if they could provide names and email addresses of colleagues who fit our recruitment criteria. We then contacted the new recruits by sending an introductory email describing the study. The interviews were held either in person at the participant’s office (n = 12, 40 %) or on the phone (n = 18, 60 %) and were approximately 1 to 1.5 h in dur- ation. The majority of interviews were conducted by the first author (LN) and the remaining by a research assistant, all interviews were recorded and transcribed. After the first six interviews were transcribed, the re- search team (LN & T S-H) met and reviewed the tran- scripts to fine tune the interview protocol.
Data analysis
In this exploratory analysis we wanted to focus on physi- cians’ conceptions of the phenomena of power in the physician-patient encounter, and thus this present ana- lysis drew on a subset of data from the larger study: We explicitly asked two open-ended interview questions within the larger study: “Do you find that there are power relations in your interactions with patients?” And “How do you deal with these power relations if you experience that they are there?”. and in this current ana- lysis, we focused on responses to these two interview questions. Follow up questions and probing techniques were also used to stimulate more information, such as “can you tell me more about that?” or “right, I see”. How- ever, we also coded all content within the full transcripts and analyzed any data found that highlighted physicians’ perceptions of power dynamics as they unfold with pa- tients in the clinical context.
Analysis of data began by multiple readings of the ver- batimtranscripts. We then used LeCompte and Schensul’s [35] approach to analyzing qualitative data that involves a systematic process that takes place in three stages: (1) Item analysis, (2) Pattern analysis, and (3) Structural ana- lysis. We used each of LeCompte and Schensul’sthree tiered inductive strategy as this analytic approach involves compiling items together at the specific level and then creating more abstract statements about patterns of re- lationships in the data to generate overall insights into the topic of interest [35]. Theoretical visibility was also present throughout all stages of analysis to enhance re- search rigour [36].
(I) First, we coded the transcripts for key phrases or tracts of text related to “physician-patient power dy- namics”. We used ATLAS.ti qualitative coding software to visually display items in the margins of the program rendering visible the relationship to each other across data sets.
(II) We then engaged in pattern analysis, which in- volved a process of comparison, contrast, and integra- tion and where items are organized, associated with other items, and linked together into higher order pat- terns. Examples of themes that were generated in this stage were: “awareness of power”; “the contextual nature of power”; and “the strategic handling of power”. These patterns emerged from drawing on prior research studies, the study’s theoretical framework, and our research pur- pose. For example, in operationalizing the item “awareness of power,” we drew on Bourdieu’s [22] notion that people often experience power differently depending on the differ- ent social circumstances or fields they find themselves in.
(III) Following pattern analysis, we developed broader themes that involved blending many of the initial codes into finer tuned themes that captured similar conceptual dimensions across the data. These broader themes, for example, were named: “perceptions of holding and man- aging power”; “perceptions of being disempowered”; and “perceptions of power as non-existent”. These broader themes were then pulled together into a meaningful whole – the interpretation.
We began the interpretation by returning to the ori- ginal research purpose and reviewing the theoretical and research literature that contextualized the study. This process helped us focus the interpretation on what
others can learn from the study and how this is sup- ported by concrete, specific examples.
Trustworthiness and rigour
We employed strategies of credibility to establish qualita- tive criteria for trustworthiness and rigour in the research. To ensure credibility in an attempt to compensate for single-researcher bias, LN and T S-H engaged in re- searcher triangulation by both being involved in the analysis of data [37]. To further enhance credibility and because all steps in qualitative analysis involve acts of in- terpretation, we also engaged in peer-examination [38] that involved discussing the research process and findings with impartial colleagues. We engaged in an ongoing dialogue with Dr. Glenn Regehr (a well-respected scholar in the field of medical education) and Wendy Hartford (a research assistant who read all of the interview transcripts), comparing insights about our emerging themes and confirming the reliability of our analysis of data. Finally, credibility was ensured by engaging in a thick description of the research process so the reader would be able to follow the research process, such as rational for the study, data collection, and analytic process. These de- tailed descriptions allow others to be able to determine if the insights can be transferred to their local context and setting [39].
* Correspondence: jfshapir@uci.edu
1Department of Family Medicine, University of California Irvine School of Medicine, 101 City Dr. South, Bldg 200, Rte 81, Ste 835, Orange, CA 92868, USA
Methods
Data analysis
Student projects were identified as the unit of analysis. The projects were first reviewed by a research team con- sisting of the first author and several medical students. Using a grounded theory approach [39, 40], each re- viewer independently studied a subset of the projects 2–3times,“deconstructing” both individual themes and emotions expressed in the projects. The research team compared their initial observations in an iterative process that involved both ongoing coding and identifica- tion of new codes as needed. Projects coded earlier were reviewed to ensure inclusion of more recently discovered categories. We grouped the codes used in scoring each project into broader categories addressing the theme(s) and emotions expressed in each project. The research team members met as a group and by email to discuss category issues, refine the scoring options, and resolve differences. Using this method, numerical counts and frequency distributions were computed for all categories and subcategories.
Codes included year project was completed, gender of student(s) completing project, type of project (artistic medium employed), and point of view represented (medical student’s, patient’s, family member’s, or resident/attendings’). In our analysis of type of project, we examined poetry and prose separately, in case different types of writing emphasized different themes and emotions. We also identified theme and emotion-based codes. Themes referred to the main point, focus, or message of the project. Emotional expression included all the emotions expressed in the project. Each project could be coded multiple times to ensure that all themes, emotions, and perspectives were captured. Forty-two theme codes and 31 emotion codes were identified.
We also considered regroupings of related content themes, for example combing various codes into an um- brella grouping that we re-labeled patient/relationship- centered care. We also summarized emotional tone into categories of positive (13 codes), reflective (3 codes), and negative (15 codes). These determinations were based on face validity. We further conducted analyses examin- ing the interaction of themes and emotions. To facilitate interpretation of these complex relationships, we calcu- lated the average number of emotions per theme so that we could determine unusually high or low frequencies of emotions. As well, we coded for shifts in emotions and attitudes within a given project. Finally we considered the data by year of project (collapsed into three approxi- mately equal groups: Group 1, 2002–2005, N=181;Group 2, 2006–2008, N=156; Group 3, 2009–2013, N=185)and gender of student to identify differences or patterns.
Cultural implications of mentoring in sub-Saharan Africa: a qualitative study (Med Educ, 2016)
Adam P Sawatsky,1 Natasha Parekh,2 Adamson S Muula,3 Ihunanya Mbata4 & Thuy Bui5
1Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
2Internal Medicine Residency,University of Pittsburgh School of Medicine,UPMCMontefioreHospital, Pittsburgh, Pennsylvania,USA
3Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
4TeamHealth Oak Ridge Methodist Medical Center, Hospitalist Medical Group, Oak Ridge, Tennessee, USA
5Division of General Internal Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore Hospital, Pittsburgh, Pennsylvania, USA
Correspondence: Adam P Sawatsky, Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA. Tel: 00 1 507 284 8913; E-mail: sawatsky.adam@mayo. edu
METHODS
We conducted a cross-sectional, qualitative study using in-depth, semi-structured interviews and the- matic analysis to explore the themes of culture and mentorship at the University of Malawi College of Medicine. Study team members had previous experi- ence in qualitative education research and had spent time in Malawi, and all but one (ASM) were not directly involved in education or mentoring at the College of Medicine. This study was approved by the institutional review boards of Mayo Clinic and the University of Pittsburgh, and by the Univer- sity of Malawi’s College of Medicine Research and Ethics Committee.
Context
The University of Malawi College of Medicine was started in 1991, and after 10 years had graduated 134 medical doctors.17 From 2006 to 2012, the grad- uating class grew from 24 to 47 students, with plans for continued growth.18 In 2004, the College of Med- icine began to run 4-year postgraduate programmes that lead to Master of Medicine degrees in internal medicine, paediatrics and child health, general sur- gery, and anaesthesia and ophthalmology, and has since added degrees in orthopaedics, obstetrics and gynaecology, nephrology, and emergency medi- cine.19,20 Yet there are still substantial shortages: for every 1000 people, Malawi has only 0.02 doctors, whereas Kenya has 0.18 and South Africa has 0.76 doctors.21 This has led to continued efforts to build the global health professional workforce, which include efforts to minimise medical migration by reducing recruitment in recipient countries, improve training and enhance the utilisation of non-physician health care workers.22 Medical students have identi- fied a need for mentoring, particularly for career planning and for identifying opportunities for post- graduate training.12 There is a programme in place that provides clinical supervision during clinical rota- tions for medical students in which the supervising person is designated a ‘mentor’. There are no formal mentoring programmes for interns, registrars or junior faculty staff, but they are encouraged to estab- lish mentoring relationships.
Participants
Using criterion sampling, we identified our initial interview candidates among Year 4 medical stu- dents, interns, registrars (i.e. residents) and faculty staff. We sampled participants at different academic levels, choosing Year 4 medical students because they have some clinical experience, but are distinct from interns. We sampled registrars and faculty staff across several specialties to get a broad perspective. We then used a snowballing technique to identify additional participants who would be likely to yield valuable information on the subject.23 We enlisted the help of student representatives to invite students to participate. We used department heads and lead- ers in the College of Medicine to assist in identify- ing interns, registrars and faculty members for participation; these leaders only provided lists of potential participants and were not actively involved in recruitment. Participants were given a medical penlight as a token of appreciation for their partici- pation.
Interviews
Participants underwent a semi-structured, one-to- one interview. Interviews were conducted by study team members who were not involved in the train- ing programmes at the University of Malawi College of Medicine, and therefore were potentially neutral observers (APS, NP and IM). The interviews were audio-recorded and transcribed verbatim. The inter- view guides were developed through an iterative process among research team members from the University of Malawi College of Medicine, the Mayo Clinic and the University of Pittsburgh School of Medicine. After an initial literature review, team members discussed important issues relating to aspects of mentoring and generated an initial list of questions that were organised into four interview guides, one for each participant group (medical stu- dents, interns, registrars and faculty staff). The study team revised each of the guides, which were then piloted and further refined for clarity. Each inter- view lasted 22–72 minutes (average: 37 minutes). A copy of the interview guide is available online (Appendix S1).
Data processing
The transcriptions were de-identified prior to analy- sis and uploaded to NVivo Version 10.0 (QSR Inter- national Pty Ltd, Melbourne, Vic., Australia), a software program that supports the analysis of quali- tative data. Three investigators reviewed a portion of the transcripts (seven of 41) and developed a code- book through open coding. The codebook was applied to each of the subsequent transcripts inde- pendently and in duplicate; differences were resolved through discussion.
Thematic analysis
We used the process of thematic analysis to conduct an exploratory analysis of the data.24 Study team members reviewed interviews and wrote analytic memos throughout the course of data collection, which began the analysis process and aided in the determining of thematic saturation. We continued to conduct interviews until no new themes were identified in the iterative discussion among study investigators. When we had completed the process of coding, we reviewed reports of quotations across interviews within each of the final codes to identify recurrent patterns from which major themes emerged in the course of our ongoing discussion. Using Sambunjak’s proposed ecological model of mentoring in academic medicine,6 we further cate- gorised themes and chose exemplary quotations.
Sequencing learning experiences to engage different level learners in the workplace: An interview study with excellent clinical teachers (Med Teach, 2015)
H. CARRIE CHEN1, PATRICIA O’SULLIVAN1, ARIANNE TEHERANI1, SHANNON FOGH1, BRENT KOBASHI1
& OLLE TEN CATE2
1University of California, USA, 2University Medical Center Utrecht, The Netherlands
Methods
Design
This was a single institution qualitative interview study of teaching practices among excellent clinical teachers. We selected a grounded theory approach from a constructivist perspective in order to develop an understanding and model for teacher selection of learning experiences for different level learners in clinical workplaces. By selecting a constructivist perspective, we acknowledge that teachers may conceptualize this process in different ways and that our understanding is an interpretive one (Watling & Lingard 2012; Creswell 2013; O’Brien et al. 2014).
Context
We conducted this study at the University of California San Francisco (UCSF) School of Medicine, and with ethical approval of the UCSF institutional review board. The UCSF undergraduate and graduate medical education programs are consistently ranked among the best in the United States (US News and World Report 2014). UCSF has an Academy of Medical Educators (AME) where the members are selected via an external review process based on their excellence in direct teaching and accomplishments in an additional area of medical education such as curricular development, advising/mentor- ing, educational administration/leadership or educational best research. AME members exemplify the teachers at UCSF and represent 4–5% of the faculty across all core teaching sites, departments and clinical and classroom settings (Cooke et al. 2003).
Participants
We used purposeful sampling methods to select participants who were most likely to provide the richest information about the selection of clinical learning activities for multiple levels of learners (Coyne 1997; Creswell 2013). We defined clinical teachers as physician faculty members who directly supervised learners in the clinical environment and who cared for patients jointly with the learner. These teachers were responsible residents/ simultaneously for both medical students and fellows who were on clinical rotations for their individual training programs with primary learning goals relating to patient care competencies. We considered medical students at any level of training, but primarily clerkship students, as junior learners; interns as intermediate or more advanced learners and senior residents/fellows as senior learners.
We first used criterion sampling to pick participants who met our pre-specified criteria of: (1) membership in the UCSF AME, (2) practicing physician and (3) taught learners of multiple levels of training in the clinical setting (Coyne 1997; Creswell 2013). Seventy-seven clinical teachers met these criteria. We then used theoretical sampling to select individ- uals based on whom we predicted would add new and varying perspectives on teaching (Coyne 1997; Watling & Lingard 2012; Creswell 2013). For instance, we anticipated that clinical teachers from different specialties (e.g. surgery versus psychiatry) or who work in dissimilar clinical settings (e.g. intensive care unit versus outpatient clinic) might have different approaches. Therefore, we specifically sampled from a variety of specialties as well as a range of inpatient and outpatient clinical settings. When emerging themes from early interviews suggested a potential difference in perspec- tive among teachers from procedural specialties, we explicitly recruited additional participants from procedural specialties to further explore their perspectives. We accomplished this by sending invitations to participate in individual interviews in multiple waves, selecting who was invited in each be inter- successive wave based on who had agreed to when we viewed. We stopped our recruitment reached theoretical saturation, at which point invitations to 46 of the 77 current physician AME members had been sent.
Instrument
Because we wanted to explore teacher selection of clinical workplace activities for different level learners, which may be a deliberate approach to structuring clinical learning, we used the framework of Collins’ cognitive apprenticeship and curricular sequencing (Collins 2005) to inform the develop- ment of an interview guide. To allow more open discussion, we did not include specific terminology from those frame- works in our interview questions or probes. The guide for our semi-structured interviews included the following questions: (1) Please describe your approach to teach learners at different levels in a clinical setting. (2) How did you develop your current approach to work with learners at different levels? (3) What role, if any, do you think faculty play in promoting the developmental progression of learners in the clinical settings? How might the faculty do a better job of this? (4) Do you have other comments about your teaching experiences with learners at different levels? We piloted the interview guide with experienced teachers who were not in the AME and made minor edits to the probes before using the guide with study participants.
Two authors (BK and SF), who were non-AME junior clinician educators, trained in interview methods, conducted the semi- structured interviews. As non-AME members, they were not well known to the study participants and could function as outsiders (Creswell 2013). However, they were also clinical teachers with insider knowledge of the teaching roles and contexts of their interviewees. Each interviewed approximately half of the study participants either in-person or by telephone between January 2012 and March 2013. They debriefed their interviews with a third author (HCC) who, as an AME member meeting study criteria, was fully positioned as an insider. This facilitated understanding and appreciation of complexity and patterns present in the data while avoiding an insider’s influence on the data collection. Interviews averaged 30min- utes in length (range 15–50 minutes). All interviews were audio-recorded and the audio files were transcribed verbatim by an external service and de-identified.
Data analysis
Consistent with our grounded theory approach, we carried out inductive thematic analysis of our data using an iterative process during and after data collection. In inductive thematic analysis, themes are not imposed, but emerge naturally from the data (Bowen 2006). Though we had a cognitive appren- ticeship and curricular sequencing framework in mind when developing our interview guide, we took this open approach to our data analysis to allow for emergence of potential additional elements and concepts. To ensure analytical rigor, we used multiple coders for investigator triangulation (Creswell 2013). After familiarizing ourselves with the tran- scripts, the three authors who are clinical teachers (HCC, BK and SF) performed initial open coding of the same six randomly selected transcripts to identify codes. We compared our coding lists and reconciled differences. We developed a codebook for thematic analysis and two authors (either HCC and BK or HCC and SF) independently applied it to all transcripts for open and axial coding (Corbin & Strauss 2008; Creswell 2013). The authors met and discussed all transcripts and reconciled any discrepancies.
We then organized the emergent themes using the sensitizing concepts of cognitive apprenticeship and curricular sequencing. Sensitizing concepts are concepts brought to data analysis to allow for a frame of reference in organizing and reporting the emergent themes (Bowen 2006). Using the organizing framework of cognitive apprenticeships and cur- ricular sequencing, one author (HCC) took the lead in further abstracting, organizing and synthesizing the themes into a cohesive model grounded in the data. To maintain reflexivity, these final phases of analyses involved discussions with the larger study team (Creswell 2013). The three non-clinician team members (PO’S, AT and OtC), one of whom was from outside UCSF (OtC), functioned as outsiders to provide diverse perspectives and challenge assumptions. They were in agree- ment with the model and themes identified.
We used Dedoose Version 4.12.4 (http://www.dedoose.- com) for our data organization and analyses. As a part of our analyses, we looked at frequency of codes, co-occurrence of codes and stratification of codes by years of teaching experi- ence. We reached saturation within our sample; we did not discover new codes or themes despite additional sampling of clinical teachers from a variety of specialties and clinical settings. Also, the amount of data we gathered was sufficient to inform our understanding of teacher selection of learning experiences for different level learners (Morse 1995; Watling & Lingard 2012).
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