Rietmeijer Chris B T, Huisman Daniëlle, Blankenstein Annette H, de Vries Henk, Scheele Fedde, Kramer Anneke W M, Teunissen Pim W
Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Amsterdam, The Netherlands.
School of Medical Sciences, VU University Medical Centre, Amsterdam, The Netherlands.
Med Educ. 2018 Jul 24;52(9):981-91. doi: 10.1111/medu.13631.
Direct observation (DO) of residents' performance, despite the importance that is ascribed to it, does not readily fit in with the practice of postgraduate medical education (PGME); it is infrequent and the quality of observation may be poor in spite of ongoing efforts towards improvement. In recent literature, DO is mostly portrayed as a means to gather information on the performance of residents for purposes of feedback and assessment. The role of DO in PGME is likely to be more complex and poorly understood in the era of outcome-based education. By exploring the possible complexity of DO in workplace learning, our research aims to contribute to a better use of DO in the practice of PGME.
Constructivist grounded theory informed our data collection and analysis. Data collection involved focus group sessions with supervisors in Dutch general practice who were invited to discuss the manifestations, meanings and effects of DO of technical skills. Theoretical sufficiency was achieved after four focus groups, with a total of 28 participants being included.
We found four patterns of DO of technical skills: initial planned DO sessions; resident-initiated ad hoc DO; supervisor-initiated ad hoc DO, and continued planned DO sessions. Different patterns of DO related to varying meanings, such as checking or trusting, and effects, such as learning a new skill or experiencing emotional discomfort, all of them concerning the training relationship, patient safety or residents' learning.
Direct observation, to supervisors, means much more than gathering information for purposes of feedback and assessment. Planned DO sessions are an important routine during the initiation phase of a training relationship. Continued planned bidirectional DO sessions, although infrequently practised, potentially combine most benefits with least side-effects of DO. Ad hoc DO, although much relied upon, is often hampered by internal tensions in supervisors, residents or both.
尽管直接观察（DO）住院医师的表现被认为很重要，但它并不容易融入毕业后医学教育（PGME）的实践中；这种观察很少进行，而且尽管一直在努力改进，但观察质量可能仍然很差。在最近的文献中，直接观察大多被描述为一种收集住院医师表现信息以进行反馈和评估的手段。在基于结果的教育时代，直接观察在毕业后医学教育中的作用可能更为复杂且鲜为人知。通过探索直接观察在工作场所学习中可能存在的复杂性，我们的研究旨在促进在毕业后医学教育实践中更好地利用直接观察。
建构主义扎根理论为我们的数据收集和分析提供了指导。数据收集包括与荷兰全科医疗的带教老师进行焦点小组讨论，邀请他们讨论技术技能直接观察的表现、意义和效果。在进行了四个焦点小组讨论后达到了理论饱和，总共纳入了28名参与者。
我们发现了技术技能直接观察的四种模式：最初计划好的直接观察课程；住院医师发起的临时直接观察；带教老师发起的临时直接观察，以及持续计划好的直接观察课程。不同的直接观察模式与不同的意义相关，如检查或信任，以及不同的效果相关，如学习新技能或经历情绪不适，所有这些都涉及培训关系、患者安全或住院医师的学习。
对带教老师来说，直接观察的意义远不止于为反馈和评估收集信息。计划好的直接观察课程是培训关系开始阶段的一项重要常规活动。持续计划好的双向直接观察课程，尽管很少实施，但可能将直接观察的最大益处与最小副作用结合起来。临时直接观察尽管被大量依赖，但往往受到带教老师、住院医师或双方内部矛盾的阻碍。
