Northern Medical Program, University of Northern British Columbia, Prince George, British Columbia, Canada.
Emergency Medicine, Stanford Medicine, Stanford University, Stanford, California, USA.
Med Educ. 2020 Dec;54(12):1148-1158. doi: 10.1111/medu.14271. Epub 2020 Aug 5.
Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee.
Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place.
Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility.
Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.
尽管针对未能淘汰表现不佳的学员这一现象提出了一些基于研究的解决方案，但未能充分记录观察到的学员不称职情况仍持续存在。如果评估语言与主管人员对不称职的概念不一致，则可能会阻碍记录。由于框架倾向于将胜任力逐项列出，而对不称职的情况则含糊不清，因此通过更好地理解和描述主管人员在面对可能不称职的学员时的经历，可以改进评估设计。
我们采用建构主义扎根理论方法，使用恒定性比较方法进行分析，该方法具有迭代性并为数据收集提供信息。我们采访了 22 名医生，了解他们在监督表现不称职的学员时的经验；我们很快发现他们对“不称职”一词感到不满，因此我们开始用“表现不佳”来代替。
医生们首先有一个信念和期望：所有学员都应该有能力通过将所学知识应用于后续临床经验来学习和进步。因此，表现不佳是出乎意料的，引起了主管人员的怀疑，他们为令人惊讶的证据寻找替代解释。主管人员将表现不佳的情况概念化为：由于疾病、生活事件或学习障碍而无法参与学习，导致进展停滞不前，或者由于缺乏兴趣、洞察力或谦逊而不愿意参与学习。
医生们将表现不佳的情况概念化为由于缺乏对学习的充分参与而导致的学习进展问题，而这种参与对强化监督没有反应。尽管未能淘汰往往被视为不愿记录表现不佳的情况，但先前的怀疑阶段会阻止对表现的有信心的记录，并延迟发现表现不佳的情况。这些发现为进一步解决表现不佳的记录不足问题提供了新的见解和可能的解决方案。
