The Teacher, the Assessor, and the Patient Protector: A Conceptual Model Describing How Context Interfaces With the Supervisory Roles of Academic Emergency Physicians

ABSTRACT

Objectives

Emergency medicine is a fast‐paced specialty that demands emergency physicians to respond to rapidly evolving patient presentations, while engaging in clinical supervision. Most research on supervisory roles has focused on the behaviors of attending physicians, including their individual preferences of supervision and level of entrustment of clinical tasks to trainees. However, less research has investigated how the clinical context (patient case complexity, workflow) influences clinical supervision. In this study, we examined how the context of the emergency department (ED) shapes the ways in which emergency physicians reconcile their competing roles in patient care and clinical supervision to optimize learning and ensure patient safety.

Methods

Emergency physicians who regularly participated in clinical supervision in several academic teaching hospitals were individually interviewed using a semi‐structured format. The interviews were transcribed and analyzed using a constructivist grounded theory approach.

Results

Sixteen emergency physicians were asked to reflect on their clinical supervisory roles in the ED. We conceptualized a model that describes three prominent roles: teacher, assessor, and patient protector. Contextual features such as trainee competence, pace of the ED, patient complexity, and the culture of academic medicine influenced the extent to which certain roles were considered salient at any given time.

Conclusions

This conceptual model can inform researchers and medical educators about the role of context in accentuating or minimizing various roles of emergency physicians. Identifying how context interfaces with these roles may help design faculty development initiatives aimed to navigate the tension between urgent patient care and medical education for emergency physicians.

Emergency medicine is a high‐pressure, fast‐paced specialty that demands emergency physicians to respond to undifferentiated and rapidly evolving patient presentations.1 In addition to patient care, emergency physicians in teaching hospitals are simultaneously responsible for clinical supervision. These responsibilities include 1) direct supervision that requires physical presence when trainees provide patient care; 2) indirect supervision, which entails direct supervision only when needed; and 3) clinical oversight that reviews decisions following patient care.2

Unlike other specialties within medicine where patient care and educational opportunities are more predictable and structured (e.g., surgery, primary care, oncology), acute care in emergency medicine is variable, unpredictable, and sporadic.3 In the emergency department (ED), emergency physicians are faced with the challenges of ensuring optimal patient flow and providing care that meets the urgent clinical demands of patients, while also engaging in clinical supervision.4 Thus, emergency physicians do not simply carry out their supervisory responsibilities unhindered; the context of the ED (i.e., unpredictability of patient cases, time sensitivity, and efficiency pressures) makes it especially challenging to engage fully with any one task. As a result, emergency physicians rapidly toggle between clinical care and supervisory duties.1 Emergency medicine is uniquely situated within the healthcare system to facilitate direct supervision of trainees, because both the attending physician and the trainee are almost always situated side‐by‐side within the open environment of the ED. This context is distinct from the segregated environments of hospital units or ambulatory clinics, which might be organized to optimize indirect observation.5, 6 The supervisory demands of attending physicians vary in different clinical contexts. For instance, physicians in surgical departments mainly conduct direct observation of procedural skills in the operating room.7 Inpatient clinical contexts, on the other hand, offer less direct observation but a greater focus on oversight as a form of clinical supervision, which includes the monitoring of clinical decision making.8, 9, 10 The ED provides a chaotic microcosm in which to explore the natural tensions between clinical and supervisory decision making.

Much of the research on clinical supervision has concentrated on the behaviors of attending physicians,11 including their personal characteristics and preferences for supervision, unconscious and conscious levels of cognitive processing,12, 13, 14, 15 and perceived level of entrustment of clinical tasks to trainees.16, 17, 18 However, less research has focused on how various contextual features (e.g., patient case complexity, workflow, and other demands of the clinical environment) influence physicians’ perceived role during supervision. One review underscored the importance of exploring how different contextual features influence the supervisory roles of academic physicians to fully understand how these physicians negotiate multiple responsibilities in the workplace.19

In this study, we examined how the ED context shapes the ways in which emergency physicians conceptualize their competing roles in patient care and in clinical supervision to optimize learning and ensure patient safety.

METHODS

Study Design

We used a constructivist grounded theory approach20, 21 to explore our research question. Constructivist grounded theory results in a conceptual model or theory that describes a social process in a specific context. In constructivist grounded theory, the researcher actively constructs an understanding about the phenomenon based on participants’ responses and seeks to understand the social processes when no adequate theory exists.21 This approach resulted in a deeper and more nuanced understanding of how emergency physicians create and maintain their views of their roles through dialectic processes (during individual interviews) of conferring meaning on their realities. In keeping with the constructivist grounded theory approach, we analyzed the first four transcripts and searched the literature to corroborate the initial codes. This initial set of codes informed subsequent data collection using a constant comparative method.22 During the initial analysis of four transcripts, we found that participants identified their roles mainly as teacher, assessor, and care provider without any prompts. As such, subsequent interviews incorporated a question about whether the participants saw themselves in these roles and were asked to elaborate on their responses.

We were sensitized by Goffman’s dramaturgical approach23 and more recent literature on clinical supervision.11, 17, 24, 25, 26 This approach allowed us to understand how emergency physicians present themselves when they interact with trainees, patients, or other staff in the ED. Given that we were interested in the different roles played by emergency physicians, we employed Goffman’s theory of dramaturgy to help structure our first‐order analysis of the data. Through this primary level of analysis, we paid particular attention to physicians’ use of pronouns (i.e., I, us, myself, you) as well as the nouns and adjectives they used to describe their roles. Two investigators (SAL, AA) are nonphysician PhD candidates with a disciplinary background in health sciences education and two investigators (TC, JS) are academic emergency physicians engaged in medical education research.

Study Setting and Population

Emergency physicians were recruited from a single academic emergency medicine program that consists of four teaching hospitals affiliated with McMaster University in Hamilton, Ontario, Canada. We received research ethics board approval from the Hamilton Integrated Research Ethics Board (HiREB‐2344).

In the ED, assessing resident competence requires observing many work‐based skills and tasks. The McMaster Modular Assessment Program (McMAP) is a programmatic workplace‐based assessment system that was developed to address the need to assess numerous competencies required of an emergency medicine specialist. McMAP collects and combines data from 76 unique “micro‐clinical exercise” direct observation assessment instruments, similar to mini‐entrustable professional activities, systematically mapped to key clinical tasks in emergency medicine and the CanMEDS framework.27 During each 8‐hour shift, attending physicians conduct direct observations of resident performance intercalated with their own direct patient care and ED managerial duties. Trainees usually provide direct patient care for four to 20 patients during each shift and are supervised by one or two physicians. In a typical shift, each attending usually completes one direct observation task, accompanied by a single assessment of global performance during the shift. Verbal and written feedback is also given. Rarely, physicians will provide written assessments on more than one task; also, on shifts where a trainee is supervised by more than one attending physician, it is common for each attending to separately assess the trainee.

Sampling and Recruitment

Emergency physicians were eligible if they had participated in McMAP as a faculty member. In keeping with constructivist grounded theory, we used snowball sampling to identify participants who could richly contribute to our understanding of the multiple roles of emergency physicians during direct observation encounters with residents. The eligible emergency physicians were recommended by the McMaster emergency medicine residency program director and subsequent individuals were recommended by other participants.

Data Collection

We collected data from January 2016 to September 2017. Of the 24 nominated and eligible emergency physicians, 16 emergency physicians (67%) participated (Table 1). Data were collected using semi‐structured, audio‐recorded interviews (for the interview script, see Data Supplement S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10431/full). Neither of the two interviewers (SAL, AA) were affiliated with the residency training program. We pilot tested the interview guide with two emergency physicians for feasibility and clarity of the questions. No questions required modification; thus, data from these interviews were included for qualitative analysis. Data collection and analysis occurred concurrently, and interview questions were subsequently modified to better explore potential themes. We collected data until theoretical saturation was reached.

Table 1.

Participant demographics

Sex
Female	8 (50)
Male	8 (50)
Training pathway
Royal College of Physicians and Surgeons of Canada	13 (81)
Pediatric Emergency Medicine Fellowship	2 (13)
Canadian College of Family Practice Enhanced Skills	1 (6)
Program Pathway (CCFP‐EM)
Experience using McMAP as a resident	5 (31)
Years in practice
<1	3 (19)
1 to 5	8 (50)
6 to 10	2 (13)
11 to 15	1 (6)
>16	2 (12)

Data are reported as n (%).

Data Management

The audio recordings of all interviews were transcribed and deidentified by a contracted professional transcriber. The deidentified interviews were imported into MAXQDA Analytics Pro 12 (VERBI Software) to assist with coding and organization.

Data Analysis

We analyzed data using constant comparison with concurrent collection and analysis of data, each informing the other. Analysis of the data was conducted to explore concepts related to supervisory roles, professional identity, assessment, and feedback. Two investigators (SAL, AA) read each transcript independently and in duplicate as the interviews were transcribed. They met to discuss and refine initial codes and categories after the first four interviews. Subsequent meetings were held to further refine codes and explore new understandings of the data.

Maintaining Rigor

Several strategies were used to maintain rigor. First, credibility was achieved with the use of negative case analysis (searching for data that do not support the patterns from the analysis). Second, frequent discussion sessions with the research team about the codes and themes widened perspectives about data. Third, reflection summaries created an audit trail, which included analytical decisions made by the research team. To facilitate transferability, clear descriptions of context, participant characteristics, and data collection and analysis procedures were included in the written report.28 We completed the Standards for Reporting Qualitative Research29 checklist to maximize methodologic transparency and uptake of research findings.

RESULTS

The interviews lasted between 16 and 51 minutes (mean ± SD = 35 ± 11 minutes), totaling 229 pages of single‐spaced transcripts. Using constructivist grounded theory, we developed a model describing the different supervisory roles of the emergency physician. Our coding and categorization resulted in the classification of data into three key roles that coexisted and overlapped these roles as the teacher, assessor, and patient protector. Our findings showed that these roles were accentuated or minimized by key contextual features, including trainee competence, pace of the ED, patient complexity, and the culture of academic medicine. Each imbrication of any two roles was associated with a predominant supervisory approach (informal coaching, helicoptering, or hands‐on approach). Each element of this model (Figure 1) is examined in detail below and illuminated using participants’ quotes. We also report the contextual features that contribute in accentuating or minimizing each role.

Figure 1.

A conceptual model on the triality of the supervising emergency physician: 1) providing proper supervision and surveillance to ensure patient safety, 2) fostering a learning environment conducive to the trainees’ professional development, and 3) performing assessments for the training program. The overlapping roles explained the areas of possible tension between the various roles and have been demarcated with choice descriptions based on our analysis. At the center of our model is where all three roles overlap.

The Main Roles and Areas of Overlap

Role 1: The Teacher

Emergency physicians placed a heavy emphasis on teaching and role modeling as part of their physician responsibility. One participant described, “So, obviously, role number one is direct patient care. But I see a significant responsibility as a physician for teaching, which is why I work at an academic center” (P16). Most emergency physicians identified with the teacher role when assessing trainees. They described this role as the “role model” and “advisor” for trainees. During each encounter, the teacher imparts clinical knowledge and facilitates learning, provides external input and insight, celebrates trainees’ achievements, and leads by role modeling the appropriate skills and attitudes required to become a competent physician.

Being a good “role model” for trainees was important to participants' vocation. For example, one participant shared: “… my role is to treat patients and be an educator as well for junior trainees and senior trainees” (P10). Emergency physicians also shared their joys of educating trainees during observations and expressed a sense of duty toward training the next generation of emergency physicians. Some emergency physicians described teaching trainees as very rewarding and considered teaching as a way of “giving back” to the system. For example, another participant said: “I feel it is something that we owe back to the system because there was a time when I was a resident and I had great teachers and they all help me get to where I am today” (P09).

Role 2: The Assessor

Many emergency physicians expressed discomfort in performing the role of the assessor, despite recognizing its purpose. Emergency physicians felt that the assessor is one who formally assesses whether the trainee has met the expectations of the postgraduate program:

The assessor … they are just simply, in a perfect world, checking off tick boxes and saying you have met the milestones or you haven't. I don't see myself as an assessor only because I don't necessarily like the cold and dispassionate role that it implies. (P18)

Some emergency physicians identified the role of assessor as someone who is objective and uses a more rigid way of assessing trainees:

I guess the assessor seems like more formal. … In my mind it is a bit more objective like you are giving a number or you are passing or failing, and you are evaluating objectively … (P16)

Some emergency physicians assessed and gave feedback while being cognizant that the trainee is one of their colleagues. These emergency physicians tended toward providing insights on performance that would help trainees learn and grow without causing undue tension. Many emergency physicians discussed the challenges of providing constructive feedback to trainees. For example, one participant stated:

In the end it is a colleague. Yes, we have a mandate to educate them but like this is somebody you could work with in the future or as a peer and you have to tell them that they aren't functioning, it is not easy. (P08)

Emergency physicians often described giving negative/constructive feedback as “challenging,” “difficult,” “awkward,” and “uncomfortable.” They disliked the process of providing negative feedback, but recognized the importance of correcting the trainee and alerting them to specific areas that might require improvement:

It is always uncomfortable to tell somebody that they did a crummy job. It is important to point it out because … they need to know so that if you don't tell them that, they can't make the improvement. (P20)

When assessing trainees during direct observation, many emergency physicians were worried that their presence would influence the trainee’s performance. Emergency physicians in our study tried to be as unobtrusive as possible to minimize any disruptions to trainee performance. Sometimes, that meant standing outside the room while the trainee was giving discharge instructions or hiding behind the curtain during a resuscitation:

I will try to hide behind the curtain. Usually the residents know I'm there, but I do find that that will sometimes be helpful. Because I think that the fact that I am standing there or the fact that I am present will invariably affect the assessment. (P02)

Role 3: The Patient Protector

Safeguarding patient safety remained a priority at all times. Even though most emergency physicians considered the relevance of all three roles, they identified with the patient protector role most strongly (if not solely), particularly when patient safety was potentially at stake. Emergency physicians were vigilant about the overall patient volume in the ED, complexity of the patient presentations, and competence of the residents. Providing high‐quality patient care in an efficient manner, educating patients and their families, and protecting patients from unnecessary harm were key features of this role. One participant shared:

So, obviously my role as a physician is to provide high‐quality care to all of the patients who come into the ED … so that the department flows and as many patients as possible receive care in as quickly a manner as possible and making sure that it is still good‐quality care. (P07)

During direct supervision, emergency physicians did not hesitate to intervene or interject a clinical encounter when the resident was communicating or performing a clinical task incorrectly or inadequately:

If the resident was doing something incorrectly or not to my preference, then I would step in … I would intervene and sometimes that makes it difficult for the resident to complete a whole task because at some point I am likely to interject … (P06)

Approach 1: Informal Coaching—The Intersection of Teacher and Assessor

Emergency physicians who identified with both the teacher and the assessor roles tended to display an ‘informal coaching’ approach. One participant suggested: “A coach is somebody who is a mentor and who seeks to improve your performance based on previous performance and based on observation. The coach is sort of like your parent who is there to help you grow and germinate” (P18).

Coaching was informal because emergency physicians did not see a formal structure in the residency program for coaching relationships to develop. Oftentimes, emergency physicians felt constrained by the existing supervision model in their clinical context:

In the current supervision model in most places there is … no mechanism for coaching. At the end of the day I [am] still responsible for doing a summary of assessment to every trainee that I supervise. And they know that. And so it is difficult to establish a coaching relationship in the clinical setting in the current model … so I actually don't see myself as a coach on most clinical shifts … where I most see myself as a coach is when I mentor residents outside of the clinical environment … I think that in the ideal world there would be an opportunity for coaching without a summit of assessment in the clinical environment, but that is not at the moment real life. (P17)

Approach 2: Hands‐on Approach—The Intersection of Patient Protector and Teacher

During direct supervision, many of the emergency physicians felt that it was their duty to provide in‐the‐moment feedback in the clinical environment. In fact, emergency physicians voiced fear that any feedback, instruction, or direction about specific encounters given at the end of a clinical rotation would not be as effective as real‐time feedback. As a teacher and patient protector, all participants preferred to provide immediate instruction so that trainees could learn on the spot as well as to ensure patient safety. Participants often recounted their observation and instruction experiences in conjunction with their perspectives of the teacher role. For example, one participant stated: “I just think it [immediate instruction] is the best practice for teaching. I think [instructive] feedback that is really closely related to the actual performance, closely related in time I mean, is best practice” (P03).

Approach 3: Helicoptering (Safety Surveillance)—The Intersection of Patient Protector and Assessor

Emergency physicians considered safety surveillance an essential component of the roles of patient protector and assessor; they would often describe themselves as hovering over the trainee to ensure they were providing adequate patient care. When completing an assessment, all participants considered themselves to first be the patient’s physician. One participant pointed out: “If I'm directly assessing a resident then I see my role as both being the patient's physician and assessor, so … if the resident was doing something incorrectly or not to my preference then I would step in” (P06). Safety surveillance entails a combination of vigilance for patient safety and awareness of the trainee’s competence in clinical practice. One participant said: “… the more senior the trainees … I don't mind if they go and take basically full control of the patients as long as it is safe” (P19).

An Intersection of All Three Roles

The blended roles of the teacher, assessor and patient protector gave rise to the triality of the supervising emergency physician, depicted at the center of our model. Emergency physicians were mindful of all three roles: 1) the duty to provide proper supervision and surveillance to ensure patient safety, 2) fostering a learning environment conducive to the trainees’ professional development, and 3) performing assessments for the training program. During supervision, they identified themselves as taking an active role in designing personalized teaching activities and tests to make sure that trainees were developing the skills they need to become independent physicians. They saw their role as needing to “figure out how to give trainees the building blocks necessary for them to go out and perform at a high level” (P18). Participants also had a strong sense of duty to safeguard the well‐being of patients and their families and often felt that teaching or assessing during direct supervision “is sometimes in conflict with the clinical work” (P18) that they do—a challenge perhaps unique to the application of coaching to medical education.

Despite perceiving each role as unique, the three roles of patient protector, teacher, and assessor coexisted when emergency physicians described how they viewed themselves. Some emergency physicians deemed that all three roles were “equally salient” (P04). One participant shared: “You know when you are observing someone … they [the roles] are inseparable … I have to be an assessor and an educator [teacher] and a physician all at the same time” (P17).

Ultimately, the multifaceted role allowed emergency physicians to protect the safety of patients and uphold patient care expectations in the department. By diligently teaching and assessing trainees, emergency physicians felt they were ensuring the excellence of a future generation of physicians graduating from the program:

My job is to take care of children and their families and that is sort of my first identity. My next I guess hat that I wear is an educator and so it is teaching people to care for the children that I care for. So, I take that part of my job pretty seriously, because if I can't produce physicians that are qualified to take care of my own children, then I am probably not doing my job. (P18)

The Influence of Context

Context was an important contributor to the fluidity of the emergency physicians’ roles and approaches for each rotation. The emergency physicians alluded to four attributes of context (trainee competence, pace of the ED, patient complexity, and the culture of academic medicine) that determined their teaching style, level of involvement in direct patient care, entrustment, and assessment—all of which contributed to the saliency of each role (teacher, assessor, and patient protector). Contextual features often interacted with each other to result in different approaches and emphases on each role. For instance, even though emergency physicians were aware of their responsibility to teach trainees how to manage the departmental patient flow, emergency physicians could shift toward the patient protector role when the ED environment demanded it. One faculty member commented:

Moving the department volume, dealing with acuity that is my job. The senior trainee is supposed to focus on departmental flow and management. And you are supposed to teach them the tips and tricks around that and how to do it. But that being said, if the senior trainee is overwhelmed or if I feel that individual patient care is being compromised by volume or acuity, then that is where I am stepping in. (P03)

Emergency physicians judged the context of the situation before intervening in the trainee’s clinical practice during direct supervision. A participant recounted: “Like if someone was too slow [in] how they worked [but] it was something minor, then I will wait until the end of the day. But if it is something that they are actively doing wrong then I will stop them right there.” (P09)

Emergency physicians’ perceived roles and responsibilities were often shaped by the learning culture they experienced during their own residency training. When asked about their approach to teaching trainees, many emergency physicians reflected specifically on how their mentors and preceptors took an active role in their education and the strategies they used to help train and develop their own competencies during their postgraduate training:

I reflect specifically on the mentors that I have had and people that I trusted and that took an active role in my education and I asked myself what … they [did] to let me develop the way I developed. And I tried to incorporate that into how I train trainees if that makes sense. (P18)

Others accessed an “internal network of support and mentorship” (P03) within their academic department to seek advice on how to teach trainees or provide appropriate feedback. There were also opportunities for faculty development using group‐based learning, which some emergency physicians stated that they found helpful.

DISCUSSION

Our study begins to unravel the inherent complexity of the academic emergency physicians’ competing and multifaceted roles during clinical supervision: the teacher, the assessor, and the patient protector. Depending on the contextual demands of the ED (trainee competence, pace of the ED, patient complexity, and the culture of academic medicine), a physician’s perception could result in different fulfillment of their singular, dual, or multifaceted role. Blended roles may lead to specific approaches (informal coaching, hands‐on approach, or helicoptering) during direct observation. At the center of our model is where all three roles coalesce, reflecting an emergency physician that provides a safe learning environment for trainees and patients alike, while simultaneously acting as an assessor—the gatekeeper of the profession. During clinical supervision, emergency physicians must deploy some aspects of high‐quality teaching or coaching (i.e., providing feedback after observing, helping trainees reach their personal best) but also take on the roles of fulfilling emergency patient care and formally reporting the trainee’s progress back to the program administration. Patient care was paramount for all participants; their allegiance to the clinician role could not be fully seconded by the teaching or assessor role, although most emergency physicians identified with other aspects in combination.

The roles of teacher, assessor, and patient protector all correspond to the literature on clinical supervision. For instance, Gingerich and colleagues describe a clinical supervision model that combines the physicians’ tension of being responsible for the unit with the tension between patient care and teaching to illustrate four supervisory approaches, each with unique priorities influencing entrustment of clinical tasks to trainees.17 Similarly, Goldszmidt and colleagues11 identified four supervisory styles (direct care, empowerment, mixed practice, and minimalist) based on how academic physicians rationalized direct patient care, trainee oversight, and teaching activities. Most recently, Melvin and colleagues30 highlighted an inherent tension between the intentions of entrustment within a competency‐based medical education assessment program and the structural elements in the work environment. Our model sheds light on the third dimensionality to the tension of being an assessor while also supervising patient care and acting as a teacher. Prior studies have not considered the role of context and how it influences the approaches that an acute care physician (such as emergency physician) might use during supervision of trainees. Our model is especially applicable to high‐acuity teaching environments like the ED, where clinical presentations and flow of the unit are unpredictable and sporadic.

The Role of Context

Our findings emphasize the important role of context during direct observation. In our study, emergency physicians’ various roles often ebbed and flowed in a context‐dependent manner. Contextual features such as trainee competence, pace of the ED, patient complexity, and the culture of academic medicine could influence the extent to which certain roles were considered salient. For example, working with a junior trainee during a complex case often elicited a greater focus on the patient protector role while slower shifts tended to provide a greater opportunity to focus on teaching.

Emergency physicians’ perceptions of their roles may lead to differing degrees of focus on clinical versus educational duties in different contexts, which may in turn influence the amount of time they are able to allot to each role. For example, emergency physicians who perceive themselves primarily as clinicians, or those who are temporarily forced to focus more on their clinical duties (e.g., when dealing with a very sick patient), may be limited in the amount of time they are able to spend in the teacher and assessor roles. Similar to our findings, Meeuwissen and colleagues31 noted how academic physicians’ conceptualizations and enactments of their role as mentors for medical students could be informed by the contextual demands of the work setting. We did not ask emergency physicians about the amount of time spent on each role and the extent to which they shift and change; future studies should examine the ways in which workplace systems and professional roles interact.

What Our Model Adds

Academic physicians have been advised to acknowledge that lines between educational and clinical roles are often blurred.32 Our model may have some explanatory value. By highlighting three unique yet intersecting roles of our emergency physicians who supervise postgraduate trainees, we shed light on how these individuals blur the distinctions between their teaching, assessment, and clinical roles depending on the context. We presented and described these roles in our model and provided empirical evidence on how and in what contexts these roles overlap. We also identified corresponding approaches that emergency physicians tend to use when two roles overlap.

Our work extends the growing body of literature that dissects the multifaceted role of academic physicians, particularly during direct supervision. Similar to a study by Watling and LaDonna24 on academic physicians, we found that emergency physicians often step in when patient safety is at stake, switching from an educational role (assessor or teacher) to the patient protector role. Our findings echo prior research findings that describe the competing demands and responsibilities of academic physicians during clinical supervision.33, 34 Surgeons in one study by Klasen et al.7 admitted to occassionally allowing trainees to fail for education benefit, while trying to balance patient safety and trainee learning. In our model, we consider the three simultaneous roles of the teacher, assessor, and patient protector as overlapping, dynamic constructs that shift in their degree of imbrication as a result of contextual features. Tension exists at the clinical level, as physicians are often asked to both assess and teach the trainee simultaneously, while taking on the burden of ensuring patient safety within existing patient care systems.30, 35, 36

Our findings also brought to light how seamlessly emergency physicians transitioned between their various roles and supervisory approaches, in a context‐dependent manner. There may be unique settings in which teachers can focus more on the teaching role and, likewise, opportunities for assessors to focus on their assessment role—however, our model suggests that a sole focus on only one of these is virtually impossible in the ED since patient care will always factor into creating a blended role for the emergency physician.

Our model can inform researchers and medical educators about how emergency physicians may have various roles that are fostered simultaneously in the ED. Our model may also offer clarity to the overlapping roles and describe how these roles interact and coexist. Identifying the roles and the areas of overlap may help design faculty development initiatives that can help emergency physicians navigate the tension between urgent patient care and medical education. For example, in faculty development sessions, one might highlight how emergency physicians should not “helicopter” too much with senior trainees who have consistently demonstrated competence within a competency‐based system. Faculty might also need to be reminded that despite having a desire for teaching, they must also attend to their duties as an assessor. This ensures that patients are adequately protected from trainees who are not yet competent and that the postgraduate training program can fulfill its educational mandate to formally assess trainees in workplace settings. As suggested by our participants, small‐group learning and case‐based discussions may be particularly well suited to helping with faculty development on this topic; cases might specifically be created to encompass physicians’ overlapping roles and the tensions created by the roles.

LIMITATIONS

Since this is a qualitative study, we did not attempt to quantify the relationship between the various roles nor any weightings or degrees of affect between the model and the context. Our findings are also based on emergency physicians who agreed to be interviewed; it is possible that these emergency physicians have different viewpoints from those who were not interviewed. Our snowball sampling technique may have been prone to a selection bias toward those who are more engaged, either consciously or unconsciously. Participants in our study had various training backgrounds (pediatrics, family medicine, emergency medicine) and worked at different hospitals, which suggests that our findings may be transferable to other specialty areas in medicine. However, our conceptual model needs to be tested in other specialty areas and clinical settings to confirm its applicability beyond the academic emergency medicine context. Nonetheless, the resonance of our findings with existing literature on understanding the academic physicians’ roles provides some reassurance that we identified more than just a local phenomenon.

Our findings may have limited transferability because this study was conducted at a site with a rich culture of workplace‐based assessment (WBA) and feedback precipitated by the McMAP.37, 38 Physicians who conduct clinical supervision at other sites who do not have a similar robustness in their assessment and feedback culture may not share the same views. However, as WBAs become more of a standard across training programs, the experiences of other clinical supervisors may grow to align with our findings.

While we titled one of our approaches “informal coaching,” we are aware that medicine’s lack of a clear definition for the coaching role has thus far compromised its ability to formally train attending physicians to become coaches.24 As such, we have kept this as a component of the triality conceptualization where the teacher and assessor roles overlap. To adopt coaching approaches in medicine, we must pay attention to how we define coaching and the responsibilities that come with it.24, 39 Existing literature reveals a conceptual tension, as researchers often use “coaching” interchangeably with “supervising” or “teaching.”24, 26, 40 Our model indicates that coaching may be a separate phenomenon that lies at the intersection of teaching and assessing.

CONCLUSIONS

In addition to clinical supervision, emergency physicians are faced with the challenges of ensuring optimal patient flow and providing care to the urgent and unpredictable clinical demands of patients. The majority of existing models focus on the attending physicians’ supervisory styles and their preferences during supervision;11, 17, 25, 41 however, the impact of context on these supervisory styles and approaches should be further examined to refine these models. In our study, we examined how context accentuates or minimizes the roles of teacher, assessor, and patient protector, lending legitimacy to the so‐called “blurring of lines” between various physician roles.

The authors thank all participants who took time to be interviewed for this study.

Supporting information

Data Supplement S1. Interview Guide.

AEM Education and Training 2021;5:52–62