Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers

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Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers
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English
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Gonzalo, Jed D.
Heist, Brain S.
Duffy, Briar L.
Dyrbye, Liselotte
Fagan, Mark J.
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Bio Med Central (BMC Medical Education)
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Background: Competency-based medical education increasingly recognizes the importance of observation, feedback, and reflection for trainee development. Although bedside rounds provide opportunities for authentic workplace-based implementation of feedback and team-based reflection strategies, this relationship has not been well described. The authors sought to understand the content and timing of feedback and team-based reflection provided by bedside teachers in the context of patient-centered bedside rounds. Methods: The authors conducted a thematic analysis qualitative study using transcripts from audio-recorded, semi-structured telephone interviews with internal medicine attending physicians (n= 34) identified as respected bedside teachers from 10 academic US institutions (2010–2011). Results: Half of the respondents (50%) were associate/full professors, with an average of 14 years of academic experience. In the context of bedside encounters, bedside teachers reported providing feedback on history-taking, physical-examination, and case-presentation skills, patient-centered communication, clinical decision-making, leadership, teaching skills, and professionalism. Positive feedback about physical-exam skills or clinical decision-making occurred during encounters, positive or constructive team-based feedback occurred immediately following encounters, and individualized constructive feedback occurred in one-on-one settings following rounding sessions. Compared to less frequent, emotionally-charged events, bedside teachers initiated team-based reflection on commonplace “teachable moments” related to patient characteristics or emotions, trainee actions and emotions, and attending physician role modeling. Conclusions: Bedside teachers use bedside rounds as a workplace-based method to provide assessment, feedback, and reflection, which are aligned with the goals of competency-based medical education. Embedded in patient-centered activities, clinical teachers should be encouraged to incorporate these content- and timing-related feedback and reflection strategies into their bedside teaching. Keywords: Medical education-qualitative methods, Medical education, Medical education-faculty development, Patient centered care
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Gonzalo et al. BMC Medical Education 2014, 14:212 http://www.biomedcentral.com/1472-6920/14/212; Pages 1-10
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doi:10.1186/1472-6920-14-212 Cite this article as: Gonzalo et al.: Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers. BMC Medical Education 2014 14:212.

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RESEARCHARTICLEOpenAccessContentandtimingoffeedbackandreflection:a multi-centerqualitativestudyofexperienced bedsideteachersJedDGonzalo1,12*,BrianSHeist2,BriarLDuffy3,LiselotteDyrbye4,MarkJFagan5,GaryFerenchick6, HeatherHarrell7,PaulAHemmer8,WalterNKernan9,JenniferRKogan10,ColleenRafferty1,RaymondWong11andMichaelDElnicki2AbstractBackground: Competency-basedmedicaleducationincreasinglyrecognizestheimportanceofobservation, feedback,andreflectionfortraineedevelopment.Althoughbedsideroundsprovideopportunitiesforauthentic workplace-basedimplementationoffeedbackandteam-basedreflectionstrategies,thisrelationshiphasnotbeen welldescribed.Theauthorssoughttounderstandthecontentandtimingoffeedbackandteam-basedreflection providedbybedsideteachersinthecontextofpatient-centeredbedsiderounds. Methods: Theauthorsconductedathematicanalysisqualitat ivestudyusingtranscriptsfromaudio-recorded, semi-structuredtelephoneinterviews withinternalmedicineattendingphysi cians(n=34)identifiedasrespected bedsideteachersfrom10academicUSinstitutions(2010 – 2011). Results: Halfoftherespondents(50%)wereassociate/fullp rofessors,withanaverageof14yearsofacademic experience.Inthecontextofbedsideencounters,bedsideteachersreportedprovidingfeedbackonhistory-taking, physical-examination,andcase-presentationskills,patient-centeredcommunication,clinicaldecision-making, leadership,teachingskills,andprofessionalism.Pos itivefeedbackaboutphysical-examskillsorclinical decision-makingoccurredduringencounters,positiveorconstructiveteam-basedfeedbackoccurredimmediately followingencounters,andindividualizedconstructivefeedbackoccurredinone-on-onesettingsfollowingrounding sessions.Comparedtolessfrequent,emotionally-chargedevents,bedsideteachersinitiatedteam-basedreflectionon commonplace “ teachablemoments ” relatedtopatientcharacteristicsoremotions,traineeactionsandemotions,and attendingphysicianrolemodeling. Conclusions: Bedsideteachersusebedsideroundsasaworkplace-basedmethodtoprovideassessment,feedback, andreflection,whicharealignedwiththegoalsofcompeten cy-basedmedicaleducation.Embeddedinpatient-centered activities,clinicalteachersshouldbeen couragedtoincorporatethe secontent-andtiming-relatedfeedbackandreflection strategiesintotheirbedsideteaching. Keywords: Medicaleducation-qualitativemet hods,Medicaleducation,Medicaleduc ation-facultydevelopment,Patient centeredcare *Correspondence: jgonzalo@hmc.psu.edu1DepartmentofMedicine,PennsylvaniaStateUniversityCollegeofMedicine, Hershey,Pennsylvania,USA12DivisionofGeneralInternalMedicine,PennStateHersheyMedical Center – HO34,500UniversityDrive,Hershey,PA17033,USA Fulllistofauthorinformationisavailableattheendofthearticle 2014Gonzaloetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle, unlessotherwisestated.Gonzalo etal.BMCMedicalEducation 2014, 14 :212 http://www.biomedcentral.com/1472-6920/14/212

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BackgroundTheimportanceofobservation,feedback,andreflection fortraineedevelopmentareincreasinglyafocusof competency-basedmedical education[1-3].In2012, theAccreditationCouncilforGraduateMedicalEducation NextAccreditationSystem(NAS)establishededucational “ milestones ” ,orobservabledevelopmentalsteps thatdescribethetrajectoryofprogressandeducational developmentoftrainees[4].Theseobservablecompetencybasedmilestonesrequirere al-time,workplace-based assessmentoftrainees ’ skills,whichincludetheprovision offeedbackandreflectionacrossvariedcontentareas tofosterthedeliberatepr acticeneededtoacquireexpertise[5-9]. Althoughtwokeyeducationalstrategiesrequiredfor traineedevelopment,feedbackandreflection,havebeen wellstudied,thefocushasbeenprimarilyonthe process withinclinicalsettings.Severalworksidentifyfeedback strategiesusedduringclinicalencountersandlist “ tips ” forincorporatingfeedbackintoclinicalsettings[2,10-14]. CoteandBordageinvestigatedthecontentofpreceptors ’ feedbackinoutpatientclinics,whichincludedreading suggestions,diagnoses,patientfollow-up,andresidents ’ concerns/feelingsaboutcases[8].Theprocessofreflectionfacilitatesthe “… analyzing,questioning,andreframing[of]anexperienceinordertomakeanassessmentofit forthepurposesoflearningand/ortoimprovepractice [2,15,16] ” .Thiseducationalmethodpromotesbothcognitiveandhumanisticgrowth,makingitanecessarycomponentofeducationalprogramsa ndhumanisticenvironments [2,17].However,evidencesuggestsreflectionisusedlittlein medicaleducation,promptingrecommendationstoraise awarenessanduseofthismetho d[2,16].Theliteraturerelatedtobothfeedbackandreflectionestablishestheconceptualframeworkforunderstand ingtheroleofthesemethods inclinically-basedscenarios.However,thecontentandtimingoffeedbackandreflectioninthecontextoftheinpatient medicinewardsarenotwellexamined. Forinternalmedicinephysicians-in-trainingwhileon inpatientwards,muchoftheauthenticworkplace-based actionoccursduringteambedsiderounds – theprocess wherebyhealthcareteamsprovidepatient-centered, point-of-careevaluation,diagnosis,andsharedclinical decision-making[18-20].Experiencedmedicaleducatorsandbedsideteachersalikehighlighttheneedfor bedsideroundstodeliverauthenticassessment,feedback, andreflection[21-23].Authenticityexistsgivenbedside encountersallowassessmentoftraineesattheapexof Miller ’ seducationalpyramid – the “ does ” ofclinicalskills [24,25].However,numerousbarriersinhospital-based settings,includingtimean dsystemsissues,limitthe realizationofbedsideroun ds[18,26-28].Inthecontext NAS,asystematicinvestigationofhowcurrent-day bedsideteachersusebedsideroundsforfeedbackand reflectioncouldassistinfacultydevelopmentefforts gearedtowardcompeten cy-basededucation. Throughsemi-structuredin terviewswithattending physicianswhoperformbedsiderounds,wesoughtto enhanceunderstandingregardingtheprocessandperceivedbenefitsofbedsideroundsinacademicsettings. Ourpriorpublicationsfromthisprojectdescribedthe value,strategiesforimplementation,andbarriersencounteredduringbedside rounds[22,23,28].Thepurposeofthisstudywastounderstandthecontentand timingoffeedbackandreflectionprovidedbybedside teachersduringbedsideroun dswithmedicalstudents andinternalmedicineresidents.MethodsStudyapproachToaddresstheresearchquestionsandadvanceourunderstandingofbedsideteachers ’ strategiesusedinfeedbackandreflectionduringbedsiderounds,athematic analysiswasused[29].Forfeedback,generalframeworks fromEndeandBranchetal.wereusedduringprobing interviewquestionsandinitialcoding[2,14].Forreflection,althoughworksbyBranchetal.informedthe understandingoftheconcep t,nostudiesaddressing reflectionduringbedsideroundswereidentified,thereforeadata-driven,inductiveapproachwasused[2,16]. Semi-structuredinterviewswerechosenratherthan surveystoexploretheresearchquestionsindetail.The studydesignandmethodsusedinthisworkaredescribedinpriorpublications;the apriori research questionsinvestigatedinthisworkweredistinctfrom theotherpublications,whichrelatedto:(1)thevalue, (2)strategiesforimplementation,and,(3)barriersencounteredduringbedsiderounds[22,23,28].ParticipantsamplingToobtainapurposivesampleofinstitutions,onecoinvestigatorfrom10U.S.institutionswasrecruited,most ofwhomwereClerkshipDirectorsinInternalMedicinemembersorhadpriorresearchexperience.Each co-investigatorrecruitedthree-sixbedsideteacherslocally consideredasbedsideteachers(e.g.receivedbedside teachingawards,identifiedbyfaculty/residents).Eachparticipanthadto:1)practiceingeneralinternalmedicine/ primarycare,2)haveservedasinpatientattending physician 2weeksinthepriortwoyears,and3)perform “ bedsiderounds ” aminimumof3weekdayswhileinpatientattending. “ Bedsiderounds ” wasdefinedas: “ The teamofmedicalproviders,includingaminimumofone houseofficerandtheattendingphysicianofrecord, presentingthepatient ’ shistoryorreviewingonephysicalexamcomponent,inadditiontodiscussingthe diagnosis/managementatthebedsideinthepatient ’ s presence ” .PotentialparticipantsweresentanemailscriptGonzalo etal.BMCMedicalEducation 2014, 14 :212 Page2of10 http://www.biomedcentral.com/1472-6920/14/212

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bytheleadinvestigatortoobtainconsentandinvitethem foraninterview.DatacollectionFromFebruary-Novemberof2010,twoinvestigators (J.G.,B.D.)performeddigi tallyrecorded,one-on-one telephoneinterviews,cons istingofclosed-endedand open-endedquestions(Appendix1).Wecommittedto interviewingatleastthreeparticipantsperinstitution regardlessifsaturationwasreachedpriortocompletionofallinterviews.Eachrecordedinterviewwas transcribedverbatimbyaprofe ssionaltranscriptionist. Afterthestudy,a$15giftcertificatewasofferedtoeach participant.DataanalysisDuringdatacollection,investigatorstooknotesand,using theprocessofconstantcomparativeanalyses,identified categoriesandgeneratedapreliminarycodebooktofacilitateanalysis.Theinitialintentwastoexplorefeedback strategies,howeverearlyanalysisrevealedparticipants weredescribinginstancesofreflectionratherthanfeedback,whichpromptedadditionalcodecreationand modification.Twoinvestigators(J.G.,B.H.)analyzed transcriptsindependentlywithdatamanagementsupportfromtheprogramAtlas.ti ™ 6.0(ScientificSoftware,Berlin,Germany).Followingindependentcoding oftwointerviews,investig atorscomparedcodesfor consistencyandagreement,resolvedanydifferencesby consensus,andupdatedthecodebook.Theremaining 32interviewswerecodedindependently,withregularadjudicationsessionstomodifythecodebook.Thetechniqueofmembercheckingwasperformedwithtwo intervieweestosupportthevalidityoftheresults[30]. Leadinvestigatorsreviewedandagreeduponallthemes andrepresentativequotations.Thestudywasexemptfrom furtherreviewbytheInstitutionalReviewBoardatthe UniversityofPittsburghandeachinstitution(Appendix2).ResultsThirty-fourinterviewswer ecompleted,with17(50%) associate/fullprofessorsand24(71%)males,withparticipantsaveraging14yearsofacademicexperience. Categoriesandthemesoffeedbackandreflectionas theyrelatetobedsideroundsaredescribedbelow.FeedbackBedsideteachersobservednumerousbedsideactivities duringteamroundingsessions,includingconversations withpatients,casepresentations,physicalexaminations, activitiesrelatedtopatient-centeredcare,andteaching moments[22].Basedupontheseobservations,respondentsdescribedseveralareasrelatedtofeedback,includingthetiming,content,leveloflearner,direction,and overallvalue.Thepredominantdescriptions,however, relatedtotiming(outlinedbelowandTable1)and content(Table1);themaincategoriesoffeedbackcontentrelatedtohistory-taking/physical-examination/casepresentationskills,patient -centeredcommunication, clinicaldecision-making,leadership/teachingskills,and professionalism. Overall,bedsideteachersbelievedbedsideencountersoffernumerousopportunitiestoobservetrainees performingactivities,whichareunrealizedwithout bedsiderounds: “ It ’ sthekeylearningsituationofthe dayinacase-based,patient-centeredfashion ” Oneattendingphysiciansummarizedthemessageofseveral participants: “ Doweuse[bedsiderounds]asasourceforfeedback? Yeah,alot.Yougleanhugeamountsofinformation aboutaresident,moreinareasofprofessional behavior,interpersonalskills,managementtechniques, abilitytoleadateammoresothanfactualdatathat comesupatthebedside ” Anotherattendingphysiciancommented: “ It ’ soneofthefewtimespeopleareworkingwith [trainees]directlyontheirclinicalskills.Theyaren ’ t usuallyobserveddoinganexamortalkingtopatients sotheydon ’ tgetspecificfeedbackotherthan[the] bedsideroundingsituation ” .DuringthebedsideencounterAttendingphysiciansusedtimeduringbedsideencounters asopportunitiesforfeedbackinseveralways.Traineeswere providedcorrectiononphysical-examinationtechniques(e.g. correctingstethoscopemispla cement).Utilizingthebedside encounterasanopportunityforobservationandfeedbackwasexemplifiedinthefollowingcomment: “ If someonedemonstratedaphysicalexamskillandthere arewaysthatcanimprove,Ishowthemintheroom,in themoment ” Bedsideencounterswereusedtoprovidefeedbackto studentsandinternsaboutcasepresentations.Inthese instances,feedbackreinforcedactionsdonewell.Some attendingphysiciansbelievedpositivefeedbackoffered inpatientviewinstillsconfidenceinbothtraineeand patient: “ Ifitwasagreatpresentation,Isayitatthe bedside.Visualconfidenceishelpfultopatientssothat theydon ’ tfeelliketheyhavethisneophytelearning doctor ” Severalattendingphysiciansusedthebedsidetoprovideteam-basedfeedbackaboutcaredelivered.Attending physicianshighlightedhowhe/shewouldhavechosena differentcourseordecisionbaseduponinformationGonzalo etal.BMCMedicalEducation 2014, 14 :212 Page3of10 http://www.biomedcentral.com/1472-6920/14/212

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obtainedatthebedside.Forexample,oneparticipant commented: “ Alotofmyfeedbackisdirect,moretowardswhatI wouldhavedonedifferently.Idoitwhenweare talkingtothepatient.Weaddressdifferenceswemay haveabouttheassessmentorplanatthebedsideso wedon ’ tallowthepatienttobeconfused ” .ImmediatelyfollowingthebedsideencounterImmediatelyfollowingbedsideencountersoutsidepatientrooms,manyattendingphysiciansidentifiedthe Table1Timing,location,andcontentofbedsideteachers ’ feedbacktotraineesinthecontextofbedsiderounds (n=111codingreferences)Timing(Location)Frequencyofcode references – n(%)aRepresentativecontentdiscussedContent categorybDuringbedsideencounter(bedside)14(13)Insufficientphysicalexaminationperformedduringadmission.HCP Physicalexaminationinstructionorcorrection.HCP Positivefeedbackonhistoryobtained.HCP Positivefeedbackonsuperiorcasepresentation.HCP Clinicalreasoningorcaredelivered.CDM Immediatelyfollowingbedsideencounter (hallway) 48(43)Lengthyandwordycasepresentations,withsuggestionsfor improvement. HCP Reviewsuccessofbedsidecasepresentations.HCP Traineestrugglingwithsummarystatement,suggestionsfor improvement. HCP Clinicalreasoninganddecision-making,withsuggestionsfor improvement. CDM Traineesnotinformingpatientaboutwhattheyaredoing, e.g.physicalexam. PCC Traineenotspeakingtocomfortlevelofpatient.PCC Traineeusing(in)appropriateterminologyatpatientlevel.PCC Traineehoveringoverpatientduringencounter.PCC Successfulpatient-centeredcommunicationdemonstrated by teammember(s). PCC Residents ’ demonstrationofagreatteachingpointatbedside.LT Afterbedsideroundingsessions (private) 30(27)Deficienciesinnotewritingandhistoryobtained.HCP Missedimportantaspectofapatient ’ spastmedicalhistory.CDM Medicaljargonusedinappropriatelyinfrontofpatient.PCC Trainee ’ sability/deficiencytoaskapatientaverysensitive question. PCC Trainee ’ sresponseandwayof “ dealingwith ” anangrypatient.PCC Deficiencies/absenceofprovidingstudent/internfeedbackabout presentations. LT Educationalskillswithstudent/intern.LT Efficiencyskillsincoordinatingteambedsiderounds.LT Lackofleadershiproleinbedsideencounter(s).LT Aconcerninginteractionorunprofessionalbehavior/eventwith apatient. P Mid/end-of-rotation(private)19(17)Casepresentationsperformedatbedside.HCP Leadershipskillsinleadingroundsandbedsideencounters.LT Assessmentofcorecompetenciesonformalevaluations.(all)aCodereferencesindicatethenumberoftimesthecodewas “ referenced ” intheanalysis.Forexample,iffeedbackduringthebedsideencounterwasdiscussedin detail,thecodemayhavebeenreferencedmorethanonce.bContentcategory:HCP-history-taking,case-presentation,physical-examinationskills,CDM – clinicaldecision-makingandcaredelivery,PCC-patient-centered communication,LT-leadershipandteachingskills,P – professionalism.Gonzalo etal.BMCMedicalEducation 2014, 14 :212 Page4of10 http://www.biomedcentral.com/1472-6920/14/212

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advantageofhavingacaptiveteampreparedforfeedback.Thisfeedbackwastypicallyamixofbothpositive andconstructivecontent,identifyingactionsrelatedto noteworthycasepresentations,patient-centeredcommunication,clinicalreasoningorcaredelivery. Someattendingphysiciansbelievedpositivefeedbackin ateamenvironmentisimportantforallteammembers ’ educationandraisedexpectationsforfeedbackduring subsequentencounters.Onebedsideteachercommented: “ Ifaninternorstudentgaveagreathistoryor communication[skills],Idoteamfeedbackbecause everyonecanlearnfromfeedbackevenifgiventoone person.Ithastobedonecorrectlyandpeopleneedto expect[feedback] ” Whenconstructivecritiquewasprovided,contentalmost exclusivelyrelatedtoteamfunctionratherthanindividual performance.Oneparticipantstated: “ Icommentaboutthe qualityoftheencounterwiththeteam,intheformof ‘ we couldhavedonethis ” .Theseconstructivefeedbackissues relatedtounprofessionalbehavior,inadequatecommunication,orincorrectclinicalreasoning,asexemplifiedbyone participantinthecontextofadelayeddiagnosis: “ Wedobedsiderounds,rollthepatientandthey ’ vegot anearlydecubitusulcer.Wemakechangesintheircare. ThepointImakeistheimportance[of]makingsureyou areattendingtothepatienteverydayandnotfocusing onjusttheproblem,[butalso]lookingforcomplications ” Participantsalsohighlightedthevalueofcorrecting physicalexaminationinaccuracies: “ Whenthingsdon ’ tgowell,Iaddressitatthattime.A third-yearstudentpresentedapatientwhowasbacteremic anddidn ’ thearanymurmurs.WhenIlistened,therewas noquestion[therewas]anewmurmur.Westeppedout andtalkedaboutitrightthen.Isaid ‘ Let ’ sgobackin.I ’ ll tellthepatientIwanttopointsomethingout,andyou needtolistenagain.[Themurmur]wasn ’ tsubtle ” .AfterbedsideroundingsessionFollowingroundingsessionsorlaterthesameday,bedside teachersprimarilyprovidedindividualconstructivefeedbackinprivatelocations.Offeredtobothstudentsand residents,thisfeedbackwaslessfrequentthanfeedback providedimmediatelyfollowingbedsideencounters. Withresidents,participantsfocusedfeedbackonpatientcenteredcommunicationactio ns,efficiency,leadership, andteachingskills.Ifaresidentusedmedicaljargonor confusingterminology,attendingphysiciansdiscussed explicitlywhattheyobserve dwhenprovidingfeedback. Additionally,attendingphysicianshighlightedresidents ’ teachingskillsmanagingastudent/internstrugglingwith oneaspectofbedsideencounters.Similarly,insituations lackingprofessionalismorpatient-centeredcare,attending physiciansaddressedtheseissuesduringtheone-on-one privateperiod: “ Aresidentwasn ’ ttellingthepatientwhathewas doing.Thepatientsaid: ‘ Whydon ’ tyoutellmewhat youaregoingtodobeforeyoufeelmylegs?. ’ Italked totheresidentafterwards,pointingoutweneedtobe carefultoexplaineverythingwedotopatientsahead oftimeandnotassumetheyknow ” Withstudentsandinterns,attendingphysiciansprimarilydiscussedhistory-taking,case-presentation,and physical-examinationskills,patient-centeredcommunication,andclinicaldecision-making.Traineesstruggling withcasepresentations,includingorganization,length, ordevelopingsummarystatements,receivedfeedback: “ If[trainees]presentandIseeanopportunityto improve,Igivesuggestions. ‘ Youdidn ’ tneedtotalk aboutthesurgicalhistorybecauseitdidn ’ tapplyto thispatient ’ sacuterenalfailure, ’ or ‘ Youmissedan aspectoftheirpastmedicalhistory,whichwas importanttowhythey ’ rehere ” Attendingphysiciansidentifiedopportunitiestoimprovecommunicationskills,raisingawarenessofthese instancesduringfeedbackmoments: “ Iencouragethemtouselessjargon,speakatthe comfortlevelofthepatient,getateye-levelbecause they[maybe]hoveringoverthepatient,andnotbe afraidtocolorthecommunicationwithshadesofgood orbad,notjustgiveobjectiveinformationbutalsomake itclearthisisafavorableorconcerningfinding-how wefeelaboutthisfinding ” .Mid-orend-of-rotationAttendingphysiciansprovidedfeedbackatmid-and end-of-rotationsessions,fo cusinglessonspecifictaskbasedperformanceandmoreonglobalevaluation. Thiswasexemplifiedbythefollowingcomment: “ At thetwo-weekpointandend-of-the-rotation,Idon ’ ttalk aboutaspecificencounterbutmoreabouthowpeople are[performing]andACGMEcompetencies ” .Attendingphysiciansprovidedfeedbackonoveruseof “ facts andprognosticthings ” hinderingcommunication,orif atrainee “ reallyclampsup[duringencounters],wetalk abouttheirdiscomfort ” .Lastly,attendingphysiciansprovidedfeedbackontasksunspecifictobedsideactivities (butobservedatthebedside),suchashowresidents “ rantheship ” ,describingteamandleadershipskills.Gonzalo etal.BMCMedicalEducation 2014, 14 :212 Page5of10 http://www.biomedcentral.com/1472-6920/14/212

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ReflectionBedsideteachersidentifiedawiderangeofeventsstimulatingteam-basedreflectionfollowingbedsideencounters, fromsignificant,high-stakestolesspoignant,low-stakes events.Significantor “ seminalevents ” ,definedbyBranch etal.asevents “… thatuniquelyshapethevaluesandattitudesof[trainees]whowitnessandparticipateinthem,shiftingtheinformalcurriculumtowardamorehumanistic learningclimate ” ,includedsituationssuchasthebreakingof badnewsorthecommunicationofanewcancerdiagnosis [16].Oneparticipantcommented: “ Ifwehaveanextraordinaryseminalevent,[forexample]ifwehavetobreakbad news,outsidetheroom,wetalkabouthowitwent ” .These seminaleventsweredescribedasinfrequentoccurrences. Morefrequently,however,attendingphysicianshighlighted theuseof “ teachablemoments ” tostimulateteam-basedreflection.Lessimpressivethanmoreemotionally-charged seminalevents,teachablemoments “… happenthataren ’ t necessarilyontheradarscreen,butcan[be]putontheradar screen ” Bedsideteachersgenerallydescribedthreecategories ofevents,orteachablemoments,thattriggeredreflection,specificallypatients ’ characteristicsoremotions, trainees ’ actionsoremotions,andattendingphysician role-modeling(Table2).PatientcharacteristicsoremotionsActionsandresponsesbypatientsoftenstimulatedteambasedreflection.Forexample,uponexitingpatients ’ rooms, ifattendingphysiciansquestionedpatients ’ comprehension, Table2Generaltaxonomyofsituationsoccurringduringbedsideencounterstriggeringteam-basedreflection(n=47 totalcodingreferences)CategoryFrequencyofcode references – n(%)aRepresentativeexamples Patients ’ characteristics oremotions 29(62)Apatientwhowasemotionalabouthis/herdiseaseorprognosis. Apatientwhowasanxiousoruncomfortableabouthis/herdiagnosisor bedsideevent. Apatientwhodidn ’ tseemhappywiththewholegroupcomingtothebedside. Apatientwhodidn ’ tseemtowanttoansweranyquestionsinfrontoftheteam. Apatientwhoseemedangryaboutanissue/event. Acombative/ “ difficult ” patient. Socialaspectsofthepatient ’ scaseexplainingwhatisgoingon. Patientwith “ excruciatingpain ” butwearingmake-up/eyeliner. Patient ’ sunderstandingofdiseaseprocess/hospitalization. Patient ’ sresponsetobreakingofbadnews. Trainees ’ actionsoremotions12(26)Team ’ sincorrectdiagnosisonanewlyadmittedpatient. Initialbedsideencountersfortraineesnewtotheactivity. Residentorteamnotacquiringanadequatehistory,resultinginmisseddiagnoses. Residentorteamcommunicatingthediagnosisofanewcancertothepatient. Residentorteamcommunicating “ badnews ” toapatient. Residentorteamresponsetoahostilefamilymember. Residentorteamdemonstrationofpatient-centeredcommunicationskills. Team ’ sfeelingsregardingconsultingspecialist ’ srecommendations. Team ’ sfeelingsregardingeventoccurringatthebedside(e.g.encounteringa difficultpatient). Attendingphysician Rolemodeling 6(13)Attendingphysician “ settinglimits ” and “ stickingtohisguns ” withapatient whoactsout. Attendingphysiciansclinicalreasoningdemonstratedatbedside. Attendingphysician ’ scommunicationskillsatbedside,whatwentwellanddid notgowell. Attendingphysician ’ sbedsidedemonstrationofcounselingapatientabout his/herdisease.aCodereferencesindicatethenumberoftimesthecodewas “ referenced ” intheanalysis.Forexample,ifreflectionassociatedwithapatient-relatedcharacteristic wasdiscussedindetail,thecodemayhavebeenreferencedmorethanonce.Gonzalo etal.BMCMedicalEducation 2014, 14 :212 Page6of10 http://www.biomedcentral.com/1472-6920/14/212

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reflectionwasinitiatedtoexploretheteam ’ simpressionof thepatients ’ understanding.Oneattendingphysicianasked theteam: “ Didyougetthegutfeelingthepatientunderstood? Wereyoucomfortablewiththat?Doweneedtogoback inandreaddressitorcomebackthisafternoonandgo overmoredetailorassesstheirunderstanding?. ”Trainees ’ actionsoremotionsTeam-basedreflectionoftenfollowedchangesorreaffirmationoftheteams ’ clinicalreasoningandcaredeliveryor discomfort,frustration,oremotionsstemmingfroma bedsideevent.Oneattendingphysiciancommented: “ Theresidentgotahistoryonapatientwithdyspneaclearlyinheartfailure-andnevergotthehistorythis patienthadpreviouslybeendiagnosedwithheart failure.Idon ’ tknowifitwashowsheaskedthequestions. Thingslikethiscomeupandmightbeateachable moment ” .AttendingphysicianrolemodelingSimilarly,attendingphysiciansinitiatedreflectionon theirownrolemodelingofcommunicationorclinical reasoning.Anticipatingtheopportunitytoreflect,attendingphysiciansbegantheprocesspriortoentering theroomandcompleteditimmediatelyafter.Thefollowingexamplerelatedtocommunicatinganewdiagnosisofcancer: “ Let ’ ssaywe ’ vediagnosedanewcancer.I ’ llask, ‘ Have youevergivenapatientbadnews? ’ Iftheysayno,I ’ ll say, ‘ Iamgoingtorolemodelthis, ’ or,I ’ llhavethe residentdoit.Beforewegoin,I ’ ll ‘ T ’ themup, ‘ Watch howwegothroughthisprocess. ’ Thenwedoit,leave, anddebrief. ‘ Howdidthatgo?, ’‘ Whatdidyoulearn?, ’ ‘ Isthissomethingyoucanuseinthefuture? ” Whenunclearaboutadiagnosis,bedsideteachers madetheteamawareofhis/herownreflectiveprocesses abouttheirdiagnosticuncertainty.Oneattendingphysiciancommented: “ Outsidetheroom,wedebrief: ‘ Wowthatwasreally weird.Idon ’ tunderstandwhythisguy ’ sbellyisso swollenwhentheultrasoundshowsnoabnormalities. ’ So,Ireflectonmyareasofuncertaintybecauseit ’ s reallyimportanttorolemodelclinicalreasoning ” .DiscussionandconclusionsOurinterviewsrevealbedsideteachersfrequentlyassess actions,providefeedback,andinitiateteam-basedreflectionwithtraineesinthecontextofbedsiderounds.During bedsideencounters,manyattendingphysiciansprovide positivefeedbackabouthistory-taking,case-presentations, physical-examinationskillsorclinicaldecision-making, whileimmediatelyfollowingbedsideencounters,bedside teachersprovidepositiveor constructiveteam-based feedbackonskills,professionalism,andclinicaldecisionmaking.Individualizedconstructivefeedbackisofferedin private,one-on-onesettingsafterroundingsessions.Additionally,immediatelyfollowingbedsideencounters,bedsideteachersinitiateteam-basedreflectionpertainingto socially-chargedeventsand,morefrequently,commonplaceteachablemomentsrelatingtopatient-ortraineerelatedissues.Bedsideteachersusebedsideroundsasa workplace-basedmethodtoprovidefeedbackandstimulatereflection,whichalignswiththeprerequisitesof competency-basedmedicaleducation. Nearlyallparticipantsprovidefeedbacktotrainees basedonobservationsperformedduringreal-timebedsideencounters[6].Thereareseveralbenefitsofassessmentandfeedbackbasedoneventsoccurringatthe bedside.First,comparedtoclinically-removedassessments,these “ on-the-job ” eventsprovideauthentic, patient-centeredin-trainingevaluations,whicharethe cornerstoneofundergraduateandgraduatemedicaleducation[25].Second,traineeshighlyvaluefeedbackon theiractionsperformedatthebedside,associatinghighqualityinpatientteachingwithfeedbackprovidedon bedsideskillsandcasepresentations,notablyfroma crediblesource[25,31].Next,traineesmostappreciate clearandaccuratefeedbackpertainingtospecificbehaviorsratherthanundifferentiatedcommentsaboutperceptions[32].Lastly,feedbackopportunitiesarisingfrom team-basedbedsideroundsalignwithstudiessuggesting clinicalperformanceimproveswithfeedbackfocusedon trainees ’ needsandofferedbyanauthoritativeindividual,suchasanattendingphysician[18,33].Despitethese recognizedbenefits,bedsideroundsarenotcommon practice,replacedmorecommonlybyhallwayorconferenceroomdiscussions[34-36].Likewiseinmedicaleducation,studiessuggestasimilarshiftinactivitiesfrom workplace-basedassessmenttowardnon-contextually basedexperiences[35,37,38].Withoutworkplace-based educationalmethodssuchasbedsiderounds,the “ failure(s) toobtaindataorfirsthandobservationsofatrainee ’ s performance ” greatlylimitsthequalityofassessmentand feedback,andsubsequently ,traineedevelopment[14]. Anchoredinobservationandassessmentoftrainees duringpatient-centeredbedsideactivities,thecontent andtimingoffeedbackalignwithrecommendedtechniquesforprovidinghigh-qualityfeedback,whichincludebeing:well-timed,expected,regulatedinquantity, basedonfirst-handdata,andwithamutualunderstandingofgoalsbetweeneducatorandtrainee[2,11,14,22]. Appliedspecificallytoinpatientwards,bothIrby ’ sbedsideGonzalo etal.BMCMedicalEducation 2014, 14 :212 Page7of10 http://www.biomedcentral.com/1472-6920/14/212

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teachersandeducators ’“ tips ” includedebriefingimmediatelyfollowingbedsideencounters[10-13]. TheimplementationoftheACGMENASandeducational “ milestones ” requireeducationalmodelsallowing fordirectobservation,meaningfulassessmentoftrainee ’ s abilitiesinprovidingpatientcare,andfrequentformative feedbacktotraineeswithbothsignificantdeficienciesand moreadvancedskills[1,4-6,39].Ourexploratoryanalysis uncoveredthatbedsideteachersusebedsideroundsprimarilyasacontextfornear-timeformativeassessment andfeedback,specificallyrelatedtoseveralcoreACGME corecompetencies,includingpatientcare,interpersonal communication,medicalknowledgeandclinicalreasoning,professionalis m,and,throughreflectiveexercise, practice-basedlearning.Byfocusingonpatient-and trainee-centeredactivities,bedsideteachersusethe establishedandcommonplacecombinededucationand care-deliverymethodasavehicletoachievetheprerequisitesofcompetency-basededucation. Iffeedbackisusedasatoolfortheadvancementof technicalproficiency,thenreflectionleadstoindividual growthandmaturation,bothworkingsynergisticallyina trainees ’ development.Attendingphysiciansoftenuse selectbedsideoccurrencestoinitiateteam-basedreflection,primarilyfocusedoneverydaycommonplace teachablemomentsratherthanlarger-scaleandmore infrequentemotionally-chargedevents.Althoughthe bedsidehasbeenpreviouslyidentifiedasasettingin whichreflectioncouldbeusedtofosterhumanism,to ourknowledge,theseresultsarethefirsttodescribe andcharacterizereflectio nstrategiesandthetypesof eventsleadingtoreflectioninthissetting[16,40].Literaturesuggestsreflectionskillsarevitalforprofessionaldevelopmentbypromotingtheanalysisofan experienceforthepurposeoflearningandcanbedevelopedbyrepeatedguidance.Ourbedsideteachers ’ focus ofbedsideeventsforreflectionpurposesspannedfrom cognitive-basedclinicalreasoningandskilldevelopment tohumanisticcultivation,aligningwiththepreviouslyreported “ purposes ” ofreflection[17].Althoughourstudy wasnotdesignedtoprovideanexhaustiveinvestigationof reflectionevents,theseresultsprovidethefoundationfor subsequentworkthatwouldincludedevelopingamore comprehensiveunderstandingofthecontentofbedside encountersthatstimulateteam-basedreflection,andthe qualityandvalueofsuchreflectionexercisesfortrainees, particularlyinateam-basedformat. Amidstcurrentdutyhourreformandpressuresofinpatientmedicine,thesecontextually-basedstrategiesrelatingtothespecificcontentandtimingoffeedbackand reflectioncanbeincorporatedinfacultydevelopment. However,severalbarriersneedtobeaddressedpriorto facultyimplementation.First,sincecurrenteducational modelsandmanyeducationalmilestonesarerealizedin workplace-basedcontextsprimarilyatthepatient ’ sbedside(bothinpatientandoutpatient)andwithevidence suggestingfeedbackandreflectionareenhancedby skilledmentors,supervisingattendingphysiciansarein aprimepositiontoobserve,assess,providefeedback, andstimulatereflectionfortrainees[41,42].However, manyattendingphysiciansacknowledgetheydonotfeel equippedtogiveeffectivefeedback,oftenfailtoidentify deficienciesintrainees ’ clinicalskills,andstrugglewith balancingpositiveandnegativefeedback[42-44].Given thelowprevalenceofcurrent-daybedsideteaching,facultymaynotonlyneedtraininginassessmentandfeedback,butalsotheactivityofbedsiderounds[28,39]. Second,robustassessments,feedback,andreflectionrequireefficientprocessesofcare,adequatestaffing,time, andwillingnessofeducators,withoutwhichtask-focused traineesmaybelesslikelytoseekorbeofferedfeedback orreflection[41].However,asevidencedbythelow prevalenceofpatient-centeredbedsideactivities,inpatientwardsmaybealess-than-idealenvironmentfor feedbackandreflection,therebylimitingtheavailability andsuccessoftheseopportunities[6,45,46].Withthe implementationofthemilestonesandneedforworkplacebasedexperientiallearningopportunities,investigations assessingthequantityandqualityoffeedbackandreflectionallowedinourcurrentinpatientsettingsarerequired, withthegoalofaddressingpotentiallymodifiablesystems issues. Thisstudyhasseverallimitations.First,wedidnot haveindependentverificationofeachparticipants ’ expertiseinbedsiderounds.However,eachbedsideteacher metthepre-specifiedinclusioncriteria[36].Second,our studydesignonlyallowedfortheperspectiveofattendingphysicians,andthereforedidnotcapturetheperceptionsofstudents,residents,andpatients.Sinceinterviews askedbedsideteachersabouttheirrecallofactivities withoutavalidationofthesereports,theresultsare vulnerabletorecallandsocialdesirabilitybias.Additionally,sinceonlygeneralinternalmedicineattendingphysicianswereinterviewed,theseresultsmaynot begeneralizabletosubspecialtynon-medicineservices. Lastly,allinstitutionswerelargeacademiccentersand theseresultsmaynotbefullygeneralizabletosmaller teachingprograms. Ourstudyshowsthatbedsideteachersusebedside roundsasacontextforobservation,feedback,andteam-basedreflection.Embeddedinpatient-centeredactivities, thesestrategiesarevitalforfacultydevelopmentefforts, particularlyintheevolvingfieldofcompetency-based medicaleducation.EthicalapprovalEthicalapprovalhasbeengrantedorwaivedateachof theparticipatinginstitutions(seeAppendix2).Gonzalo etal.BMCMedicalEducation 2014, 14 :212 Page8of10 http://www.biomedcentral.com/1472-6920/14/212

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Appendix1SelectSurveyInstrumentItems: 1. Close-endedsurveyquestions: a. WhatisyourpositionintheGeneralInternal Medicinedivision?(open-ended) i. Assistantprofessor ii. Associateprofessor iii. Professor iv. Chair/chief v. Programdirector/associateprogramdirector/ clerkshipdirector vi. Other:_______________ b. Howmanyyearshaveyoubeenpracticingin academicmedicine?(open) i. _______________ c. Howmanyweeksintheprevioustwoyearswere youthe “ attendingofrecord ” withhousestaff? (open) i. _______________ d. Inanaverageweekof5roundingdays,how manydaysdoyouperformatleastonebedside roundingencounter? i. _______________ e. Duringyourinpatientattendingtimewith housestaff,estimatethepercentageofallpatient encountersthatare “ bedsiderounds?(open) i. _______________ f. Didyoureceiveformaleducationaboutbedside roundsduringthefollowingperiodsinyourcareer? i. Internship/residency – y/nIfyes,inwhatformatwasthiseducation provided? ii. Fellowship(ifapplicable) – y/nIfyes,inwhatformatwasthiseducation provided? iii. Facultyposition – y/nIfyes,inwhatformatwasthiseducation provided? 2. Open-endedquestions: a. Whydoyouperformbedsiderounds? i. Probe:Whyisthat?(investigatewhythe reasontheygiveisimportant). b. Doyoudebriefbedsideroundingsessions? i. Probe:Howdoyoudebriefbedsiderounding sessions? ii. Probe:Whendoesthisdebriefingoccur? iii. Probe:Wheredoesthisdebriefingoccur? iv. Probe:Doyoudebrieforprovidefeedbackat thebedside? v. Probe:Canyouprovideaspecificexample? c. Thinkaboutasuccessfulbedsiderounding encounterthatyouhadasateacherorlearner. Pleaseshareitwithme. i. Probe:Whatmadetheencountersuccessful? ii. Probe:Whatdidyoulearnfromthatexperience? d. Thinkaboutanunsuccessfulbedsiderounding encounterthatyouhadasateacherorlearner. Pleaseshareitwithme. i. Probe:Whatmadetheencountersuccessful? ii. Probe:Whatdidyoulearnfromthat experience? e. Whatarethepositiveaspectsofbedsiderounds? (Whatarethebenefitstobedsiderounds?) i. Probe:Canyouthinkofanyadditional benefits? f. Whyarebedsideroundseducationalforhousestaff?Appendix2TheparticipatinginstitutionsandrespectiveInstitutional ReviewBoard(IRB)determinationsinvolvedinthiswork were:UniversityofPittsburghSchoolofMedicine-primary site(exempt),AlpertMedicalSchoolofBrownUniversity (nothumansubjectsresearch),LomaLindaUniversity SchoolofMedicine(nothumansubjectsresearch),Mayo ClinicCollegeofMedicine(minimalriskresearch), MichiganStateUniv.Colle geofHumanMedicine(not humansubjectsresearch),PennsylvaniaStateUniversity CollegeofMedicine(exempt),PerelmanSchoolof Medicine,UniversityofPenns ylvania(exempt),Uniformed ServicesUniversityoftheHealthSciences(minimalrisk research),UniversityofFloridaCollegeofMedicine (exempt),YaleUniversitySchoolofMedicine(exempt).Competinginterests Toourknowledge,noconflictofinterest,financialorother,existsforall authors.Theviewsexpressedinthispaperarethoseoftheauthorsanddo notnecessarilyreflecttheviewsoftheUniformedServicesUniversity,the DepartmentofDefense,orotherfederalagencies.Theauthorsreportno declarationsofinterest. Authors ’ contributions JDG,DME,andBLDcontributedtostudydesign;JDG,LD,MJF,GF,HH,PAH, WNK,JRK,CR,RW,andDMEcontributedtoparticipantrecruitment,arranging datacollectionmethodsateachsite,andIRBsubmission/approval;JDGand BLDwereresponsibleforalldatacollection;JDG,BSH,BLD,andDME contributedtotheanalysisandinterpretationofdata;JDGandBSHdrafted theinitialversionofthemanuscript;alllistedauthorscriticallyreviewedand revisedthefinalsubmittedmanuscriptforintellectualcontent.Allauthors readandapprovedthefinalmanuscript. Acknowledgements Theauthorswouldliketothankallparticipantsforvolunteeringtheirtimeto beinterviewedandtheUniversityofPittsburghMedicalCenter ’ sShadyside ThomasH.Nimick,Jr.ResearchFundandtheShadysideHospitalFoundation forfundingthisproject. Authordetails1DepartmentofMedicine,PennsylvaniaStateUniversityCollegeofMedicine, Hershey,Pennsylvania,USA.2DepartmentofMedicine,Universityof PittsburghSchoolofMedicine,Pittsburgh,Pennsylvania,USA.3Department ofMedicine,UniversityofMinnesotaSchoolofMedicine,Minneapolis, Minnesota,USA.4DepartmentofMedicine,MayoClinicCollegeofMedicine, Rochester,Minnesota,USA.5DepartmentofMedicine,AlpertMedicalSchool ofBrownUniversity,Providence,RhodeIsland,USA.6DepartmentofGonzalo etal.BMCMedicalEducation 2014, 14 :212 Page9of10 http://www.biomedcentral.com/1472-6920/14/212

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Medicine,CollegeofHumanMedicine,MichiganStateUniversity,East Lansing,Michigan,USA.7DepartmentofMedicine,UniversityofFlorida CollegeofMedicine,Gainesville,Florida,USA.8DepartmentofMedicine, UniformedServicesUniversityoftheHealthSciences,Bethesda,Maryland, USA.9DepartmentofMedicine,YaleUniversitySchoolofMedicine,New Haven,Connecticut,USA.10DepartmentofMedicine,PerelmanSchoolof MedicineattheUniversityofPennsylvania,Philadelphia,Pennsylvania,USA.11DepartmentofMedicine,LomaLindaUniversitySchoolofMedicine,Loma Linda,California,USA.12DivisionofGeneralInternalMedicine,PennState HersheyMedicalCenter – HO34,500UniversityDrive,Hershey,PA17033, USA. Received:4July2014Accepted:3October2014 Published:10October2014 References1.ACGME: ACGMEOutcomesProject ;1999. 2.BranchWTJr,ParanjapeA: Feedbackandreflection:teachingmethodsfor clinicalsettings. 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JGenInternMed 2005, 20 (12):1165 – 1172. 46.HolmboeE,GinsburgS,BernabeoE: Therotationalapproachtomedical education:timetoconfrontourassumptions?MedEduc 2011, 45 (1):69 – 80.doi:10.1186/1472-6920-14-212 Citethisarticleas: Gonzalo etal. : Contentandtimingoffeedbackand reflection:amulti-centerqualitativestudyofexperiencedbedside teachers. BMCMedicalEducation 2014 14 :212.Gonzalo etal.BMCMedicalEducation 2014, 14 :212 Page10of10 http://www.biomedcentral.com/1472-6920/14/212