What happens under the flag of direct observation, and how that matters: A qualitative study in general practice residency

Abstract

Introduction

In competency-based medical education, direct observation (DO) of residents’ skills is scarce, notwithstanding its undisputed importance for credible feedback and assessment. A growing body of research is investigating this discrepancy. Strikingly, in this research, DO as a concrete educational activity tends to remain vague. In this study, we concretised DO of technical skills in postgraduate longitudinal training relationships.

Methods

Informed by constructivist grounded theory, we performed a focus group study among general practice residents. We asked residents about their experiences with different manifestations of DO of technical skills. A framework describing different DO patterns with their varied impact on learning and the training relationship was constructed and refined until theoretical sufficiency was reached.

Results

The dominant DO pattern was ad hoc, one-way DO. Importantly, in this pattern, various unpredictable, and sometimes unwanted, scenarios could occur. Residents hesitated to discuss unwanted scenarios with their supervisors, sometimes instead refraining from future requests for DO or even for help. Planned bi-directional DO sessions, though seldom practiced, contributed much to collaborative learning in a psychologically safe training relationship.

Discussion and conclusion

Patterns matter in DO. Residents and supervisors should be made aware of this and educated in maintaining an open dialogue on how to use DO for the benefit of learning and the training relationship.

Keywords:

• Assessment
• collaborative learning
• dialogue
• direct observation
• educational alliance
• feedback
• pattern theory
• residency
• residents’ agency
• technical skills
• training relationship

Acknowledgements

The authors wish to thank the residents who participated in this study. Anne de Wit, psychologist at the department of General Practice and Elderly Care Medicine at Amsterdam University Medical Center, location VUmc, Amsterdam, facilitated two of the focus groups. Marilyn Hedges provided feedback on English grammar and style.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Chris B. T. Rietmeijer

Chris B. T. Rietmeijer, MD, is a general practitioner and curriculum director at the General Practice training center of the Amsterdam University Medical centers, location Vumc. He is currently working on his PhD research concerning direct observation in GP residency.

Annette H. Blankenstein

Annette H. Blankenstein, MD, PhD, general practitioner, is senior researcher at Amsterdam University Medical Centers, location Vumc, Department of General Practice. She performed research among GP residents on using Patient Feedback, applying Palliative Care, and managing Medically Unexplained Symptoms. Until 2021 she was head of the general practice training center at Vumc.

Daniëlle Huisman

Danielle Huisman, MSc in Clinical Neuropsychology, is currently doing a PhD in Health Psychology at King’s College London, UK. Danielle previously worked as a research assistant at Amsterdam UMC, The Netherlands, on projects concerning medically unexplained physical symptoms, cardiovascular risk management, and competency-based medical education in primary care.

Henriëtte E. van der Horst

Henriëtte E. van der Horst, MD, PhD, is a professor of general practice and was head of the Department of General Practice and Elderly Care Medicine at VU medical centre until 2019. Currently, she is chair of the division Primary Care, Public Health and Methodology of Amsterdam University Medical Centres.

Anneke W. M. Kramer

Anneke W. M. Kramer, MD, PhD, is a general practitioner and professor at the Leiden University Medical Centre (LUMC), focusing on educational research in workplace learning.

Henk de Vries

Hendrik de Vries, MD, PhD, is a retired professor of Family Medicine. He developed the curriculum of clinical reasoning of the bachelor and masters medical training at Amsterdam UMC (location VUmc). He now coaches educators of trainees in Family Medicine.

Fedde Scheele

Fedde Scheele, MD, PhD, is a professor in Health Systems Innovation and Education at the departments of Science and Medicine of the VU University of Amsterdam. He practices gynaecology at the OLVG Teaching Hospital and is Dean of the OLVG Health School. He is involved in National and International projects to improve education for health professionals.

Pim W. Teunissen

Pim W. Teunissen, MD, PhD, is a professor of workplace learning in healthcare. He is director of the School of Health Professions Education at Maastricht University and also works as a gynecologist specialised in high-care obstetrics at the Maastricht University Medical Center. He chairs the redesign committee for the national residency program of the Dutch Society for Obstetrics and Gynecology.