Adopting a learning stance

Dr Leclaire, a teacher, and Dr William, a resident, have just finished a supervision session during Dr William’s family medicine rotation. As they leave, Dr Leclaire thinks, “I feel like we did a good job with the patients but I’m not so sure I’m helping this resident to progress.” And Dr William thinks, “I believe I did a good job, but I’m not sure that our discussions are going to help me to become a good family physician.”

Does this sound familiar? In the pressurized environment of the clinic, it is often difficult to make the best use of the few moments available for supervision. Where the Triple C curriculum is concerned, giving thought to supervising residents and delivering feedback to make these practices as worthwhile as possible is time well spent.

The literature confirms what we already know from experience to be the most useful strategies to enhance the development of competencies.

• Learners have to be active. This implies self- regulated learning, self-assessment, speaking up if they need something, and feedback-seeking behaviour.^1,2 Yet medical training has traditionally put students on the defensive, encouraging them to show only their strengths.³

• The supervisor’s primary responsibility is creating an atmosphere conducive to learning. The supervisor acts as a coach, encouraging residents to expand their clinical reasoning and providing them with constructive feedback on a regular basis. A good supervisor adjusts the coaching so that it is relevant to each specific situation; he or she accompanies residents as they progress.^4,5

• Together, they should adopt a collaborative approach, where each recognizes his or her responsibilities in building the relationship.^6,7

This type of supervisor-learner interaction during medical training represents a paradigm shift, requiring the dynamic to change at a very profound level. In this article, we describe the concept of an evaluation-focused stance (ES) versus a learning stance (LS) (translated from the French terms position d’évaluation and position d’apprentissage, respectively). We then report on a strategy that 2 Quebec universities have used successfully to encourage both supervisors and learners adopt an LS.

Distinction between ES and LS

The distinction between an ES and an LS was described by Giroux and Girard at the conclusion of a 15-year participatory action research project conducted at the University of Sherbrooke in Quebec.⁸ The LS and ES represent a series of ideas, emotions, behaviour, and attitudes adopted by learners in their relationships with their supervisors, based on their needs and motivations. It emphasizes the fact that some learners focus on the goal of “becoming a good family physician” while others are mostly driven by the goal of “getting good grades.” One student will see clinical situations as opportunities for real learning, openly talking about the challenges he or she is encountering and looking for answers. By contrast, another student will seek to impress, avoiding situations that could lay bare his or her weaknesses. Through their attitudes, remarks, and supervision strategies, supervisors play a crucial role in shifting the focus to an LS. If they judge a student for the difficulties he or she is encountering, that student might never voice them again.²

Clearly, evaluation is an essential part of medical training—one that coexists with the reality of learning. The LS and ES are part of a continuum, as represented in Figure 1. Students move back and forth along this continuum every day in their interactions with their supervisors. Where they are at any given moment depends on the learning situation, the students (eg, the emotions that the learning situation brings up for the student, past experiences, etc), the attitudes of their supervisors, and the teaching culture in the setting. By the very nature of their role as assessors, preceptors need to take the initiative to create an atmosphere of trust and encourage learners to adopt an LS.

Figure 1.

Continuum from an evaluation-focused stance to a learning stance

Many supervisors across Canada try intuitively to encourage their students to adopt a learning stance, to varying degrees of success. Giroux and Girard describe different strategies to help both students and preceptors adopt an LS rather than an ES on a daily basis (Table 1).⁸

Table 1.

Ranked supervision strategies that foster adoption of a learning stance: This tool was developed for the family medicine program at the University of Sherbrooke in Quebec in 2003.

RESIDENT’S PERSPECTIVE	SUPERVISOR’S PERSPECTIVE
1. Periodically identify with my supervisor where I am in my training, share my concerns, and specify my supervision goals and expectations, because it is my training	1. Periodically determine with the resident where he or she is in the training process by having the resident share concerns and specify supervision goals, because it is the resident’s training
2. Identify to what degree I feel competent in the various activities in my rotation and discuss with my supervisor the next hurdle to clear to feel more competent	2. Ask the resident about his or her feelings of competence in the rotation’s various activities and discuss what could make him or her feel more competent
3. Ask my supervisor to verbalize his or her expectations with respect to my performance given my level of training. They could be quite different from what I perceive the expectations to be	3. As the supervisor, relate my expectations in terms of performance to the resident, taking into account the resident’s expectations and objectives for his or her level of training
4. Turn off the pressure I put on myself with respect to knowledge to be gained and tasks to be accomplished and, if needed, discuss with my supervisor what is important at my level of training	4. Turn off the resident’s self-imposed pressure with respect to knowledge to be gained and tasks to be accomplished by sharing my own experiences with the resident and underscoring what is important at his or her level of training
5. Take advantage of the cases discussed to relate to my supervisor one or two questions that I have been asking myself and to answer them together	5. Take advantage of supervised cases to encourage the resident to share a question or two and arrive at an answer together
6. Negotiate specific, realistic, dedicated times with the supervisor to discuss an issue in greater depth	6. Set aside specific, realistic, dedicated times to discuss an issue in greater depth
7. Before requesting feedback, begin with a self-assessment of my work and convey it to the supervisor	7. Before providing feedback, begin by asking the resident to perform a self-assessment of his or her work and then enhance it through questioning
8. Trust myself! Congratulate myself on my successes! Validate them with my supervisor	8. Clearly underscore the resident’s successes and areas for improvement in such a way that he or she does not focus solely on the latter
9. After being supervised, discuss the area for improvement in terms of objectives to work on during the next period of supervision	9. After a supervision session, transform the area for improvement into an objective to work on during the next period of supervision
10. Listen to the positive and negative points of feedback when being supervised and discuss how the feedback received changed my self-assessment	10. Subsequent to feedback, find out how the resident has interpreted the strengths and areas for improvement and discuss how the feedback received changed his or her self-assessment
11. When facing a difficult interaction with a patient, before the interview, agree with my supervisor on an objective or intervention plan (pre-coaching) and discuss adjustments made during the interview	11. Conduct anticipatory supervision (pre-coaching) by reviewing with the resident his or her action plan and important points to consider before seeing the patient and then discuss the adjustments made during the interview
12. After a consultation with time constraints during which I felt incompetent in dealing with a difficult patient, go back over what I was able to cover during this encounter	12. After a consultation with time constraints during which the resident felt incompetent in dealing with a difficult patient, go back over what he or she was able to cover during this encounter
13. Ask the supervisor if I can observe him or her in interview situations with difficult patients so as to observe competencies and discuss them after the interview	13. Let the resident observe how we deal with difficult situations so that he or she can better see his or her competencies and discuss them after the interview
14. When the supervisor and I see patients together (eg, during hospital rounds), alternate the roles of observer and caregiver, then critique the conversations and discuss controversial issues	14. When seeing patients together with the resident (eg, during hospital rounds), alternate the roles of observer and caregiver, then critique the conversations and discuss controversial issues
15. Use video to observe myself during interviews for subsequent viewing with my supervisor to identify my strengths and means for improving my performance	15. Use video to allow the resident to observe his or her strengths and see how to improve and adopt a healthy distance with respect to his or her performance
16. Present my case to my supervisor, summarizing it as if I were transferring it to a colleague. If needed, summarize the case in writing, specifying the questions I have	16. To help the resident realize his or her synthesis skills, before discussing a case, ask the resident to summarize it and state any questions in writing as if he or she were transferring it to a colleague
17. Learn to manage my time effectively. Discuss with my supervisor how I could save time with a given patient and how I could cut down on the time taken during my interview or examination	17. Teach how to manage time effectively. Show the resident how time could have been gained with a patient, and how the interview or examination could have been shortened
18. View myself as the patient’s “attending physician” and consider the supervisor as a coach and colleague rather than simply as an evaluator	18. Invite the second-year resident to go through the next few weeks as if he or she were an attending physician and to view me as a coach or colleague with whom he or she can discuss how to improve performance
19. When a second-year resident, use the 2-piles-of-charts technique: the first pile for fast review and the second pile reviewed based on questions I have about the cases	19. With a second-year resident, use the 2-piles-of-charts technique: the first pile for fast review; the second pile for review based on the resident’s questions
20. Give feedback to the supervisor on his or her supervision, with respect to my own expectations	20. Ask the resident for feedback on my supervision

Adapted from Giroux and Girard.⁸

Workshop to foster the adoption of an LS

In the 1990s, the University of Sherbrooke introduced a workshop on the LS in an effort to encourage residents to adopt attitudes and strategies for making the most of their residency. Because they were unsure whether their supervisors shared this vision, the residents were initially reluctant to expose themselves and risk bad evaluations. The workshop was re-introduced, this time with the participation of the supervisors.⁸

The first part of the workshop introduces the notion of LS-ES. Participants are asked to come up with possible strategies, first individually and then in groups. Two actors then simulate a typical supervision session and those watching are instructed to suggest specific strategies favourable to an LS. The actors then play out the scene again, incorporating the suggestions that have been made. The result is a very convincing demonstration of active learning and the LS.

Laval University in Quebec began to use this workshop in 2010 in its efforts to find tools to support competency-based learning. Response to the workshop was so positive that Laval University decided to adopt the concepts and materials that had been developed at the University of Sherbrooke. Since 2013, all of its teaching sites have offered a 2-hour workshop at the beginning of the year that is attended by first- and second-year residents, preceptors, and other professionals involved in teaching.

Each workshop is led by 2 facilitators, 1 of whom is from outside the teaching centre. This facilitator encourages the residents to express themselves, reassuring them that their comments, which are often very emotional, will be treated confidentially. To ensure that the workshop is delivered consistently, a facilitator’s guide has been developed and workshop facilitators meet annually.

The residents and supervisors reported that they really liked the workshop and that it has had lasting and positive effects. Supervisors are more focused on learners’ needs. As one resident put it, “This is the course that has had the most impact on how I behave during supervision. I realized that my supervisors were there to help me. This was the opposite of my experience as a clerk, where I learned to hide certain things.” Second-year residents reported that attending the workshop again at the beginning of their second year was really valuable.

Tips for teaching

The LS involves a reciprocal, explicit responsibility that is shared by the learner and the supervisor; both work together to create conditions conducive to optimal learning. For example, they agree together on a strategy for discussing cases that will meet “real” needs expressed by the learner.

Both benefit when they take an honest look at where they are along the LS-ES continuum. The supervisor also benefits from adopting the LS; a proactive attitude, self-examination, collaboration, open dialogue, and feedback loops are all important aspects of lifelong learning.⁹ A supervisor’s commitment to ongoing improvement will be a source of inspiration for his or her residents.

For maximum benefit, the LS should be adopted throughout the program. Those in charge in the various rotation settings should ensure that the atmosphere and relationships are conducive to the LS and that learners will be able to trust that they have more to gain by sharing their fears and concerns than by hiding them. The general observation is that the shift results in a healthier, more constructive work environment and learning environment for all.

Tools and resources

The workshop⁸ can make it easier to apply these concepts on a daily basis and to transform the culture of teaching settings. Based on the experiences of residents and teachers in the field, a list of strategies has been developed for optimizing the LS in clinical supervision (Table 1).⁸ Supervisors will find that paying attention to the LS will be especially helpful for supervising residents who are struggling.

Adopting the LS and proactive supervision strategies will help you to make the most of what little time you have for supervision. As your clinical load gets heavier and the number of residents grows, these tools might help you to optimize your supervision time.

Conclusion

Encouraging an LS is a useful investment congruent with the Triple C curriculum. We encourage both teachers and residents to explore the concept, and to experiment with the tools. We believe that this concept will aid in the development of competence and that it could prove useful throughout the continuum of medical training.

Teaching Tips

• Students who want to take advantage of clinical activities as learning opportunities should openly discuss their challenges and seek answers. Students who are focused on getting good marks will avoid exposing themselves to scrutiny.

• In the 1990s, the University of Sherbrooke in Quebec introduced a workshop on the learning stance that encouraged residents to adopt attitudes and strategies that would make their residency as meaningful as possible. Since 2013, every teaching setting at Laval University has offered a 2-hour workshop at the beginning of each year. First- and second-year residents, preceptors, and other professionals involved in teaching attend.

• Supervisors will find that the vocabulary and concepts of the learning stance are particularly useful for working with residents who are struggling.

Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Miriam Lacasse, Teaching Moment Coordinator, at Miriam.Lacasse@fmed.ulaval.ca.