Castanelli Damian J, Weller Jennifer M, Molloy Elizabeth, Bearman Margaret
School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
Department of Anaesthesia and Perioperative Medicine, Monash Health, Clayton, VIC, Australia.
Adv Health Sci Educ Theory Pract. 2020 Mar;25(1):131-147. doi: 10.1007/s10459-019-09913-5. Epub 2019 Sep 3.
Medical educators are tasked with decisions on trainee progression and credentialing for independent clinical practice, which requires robust evidence from workplace-based assessment. It is unclear how the current promotion of workplace-based assessment as a pedagogical approach to promote learning has impacted this use of assessments for decision-making; meeting both these purposes may present unforeseen challenges. In this study we explored how supervisors make decisions on trainee progress in practice. We conducted semi-structured interviews with 19 supervisors of postgraduate anesthesia training across Australia and New Zealand and undertook thematic analysis of the transcripts. Supervisors looked beyond the formal assessment portfolio when making performance decisions. They instead used assessment 'shadow systems' based on their own observation and confidential judgements from trusted colleagues. Supervisors' decision making involved expert judgement of the perceived salient aspects of performance and the standard to be attained while making allowances for the opportunities and constraints of the local learning environment. Supervisors found making progress decisions an emotional burden. When faced with difficult decisions, they found ways to share the responsibility and balance the potential consequences for the trainee with the need to protect their patients. Viewed through the lens of community of practice theory, the development of assessment 'shadow systems' indicates a lack of alignment between local workplace assessment practices and the prescribed programmatic assessment approach to high-stakes progress decisions. Avenues for improvement include cooperative development of formal assessment processes to better meet local needs or incorporating the information in 'shadow systems' into formal assessment processes.
医学教育工作者负责就学员的进步以及独立临床实践的资质认证做出决策，这需要基于工作场所评估的有力证据。目前将基于工作场所的评估作为一种促进学习的教学方法加以推广，这对将此类评估用于决策产生了何种影响尚不清楚；同时实现这两个目的可能会带来意想不到的挑战。在本研究中，我们探讨了上级主管如何在实践中就学员的进步做出决策。我们对澳大利亚和新西兰的19位研究生麻醉培训的上级主管进行了半结构化访谈，并对访谈记录进行了主题分析。上级主管在做出绩效决策时，会超越正式的评估组合。相反，他们会基于自己的观察以及来自可信赖同事的保密判断，使用评估“影子系统”。上级主管的决策涉及对所认为的绩效显著方面以及要达到的标准进行专家判断，同时还要考虑当地学习环境的机遇和限制因素。上级主管发现做出进步决策是一种情感负担。面对艰难决策时，他们会设法分担责任，并在保护患者的需求与对学员可能产生的后果之间取得平衡。从实践共同体理论的角度来看，评估“影子系统”的发展表明，当地工作场所评估实践与用于高风险进步决策的规定性程序评估方法之间缺乏一致性。改进途径包括合作开发正式评估流程以更好地满足当地需求，或者将“影子系统”中的信息纳入正式评估流程。
