Explicating practice norms and tensions between values in resident training in family medicine

摘要

Residency programs have the intricate and complex role of training health care providers. But little is known about what residents and attendings consider norms of practice or the tensions among different values residents are expected to uphold. Thus, dialogical and reflective frameworks are being explored for resident learning. This study examined the use of facilitated conversations with groups of residents and attending physicians while reviewing video-recorded resident–patient interactions. The conversations were recorded, transcribed, and qualitatively analyzed. A total of 24 residents and 10 attendings participated in conversations while separately and in parallel groups reviewing 15 resident sessions. Residents explicated the norms of practice and evaluated their performance, which often agreed with those of attending physicians in calling out important learning opportunities. When disagreement occurred, residents’ explications of their reasoning were often relevant and, via reflection and dialogue, helped clarify intentions that were not apparent in the videos. Residents and attendings often judged actions on more than one domain of value. For instance, if a resident addressed problems, built relationships in a timely manner, and acted autonomously without jeopardizing the quality of care, she satisfactorily performed her duty. Practice norms and value struggles were addressed by participants during reviews, which provided a promising framework for learning and assessment. Also, the non-hierarchical structure opened space to acknowledge a diversity of positions and for tensions among values to be explicated.