Integrated and implicit: how residents learn CanMEDS roles by participating in practice

Abstract

Context Learning outcomes for residency training are defined in competency frameworks such as the CanMEDS framework, which ultimately aim to better prepare residents for their future tasks. Although residents’ training relies heavily on learning through participation in the workplace under the supervision of a specialist, it remains unclear how the CanMEDS framework informs practice‐based learning and daily interactions between residents and supervisors. Objectives This study aimed to explore how the CanMEDS framework informs residents’ practice‐based training and interactions with supervisors. Methods Constructivist grounded theory guided iterative data collection and analyses. Data were collected by direct observations of residents and supervisors, combined with formal and field interviews. We progressively arrived at an explanatory theory by coding and interpreting the data, building provisional theories and through continuous conversations. Data analysis drew on sensitising insights from communities of practice theory, which provided this study with a social learning perspective. Results CanMEDS roles occurred in an integrated fashion and usually remained implicit during interactions. The language of CanMEDS was not adopted in clinical practice, which seemed to impede explicit learning interactions. The CanMEDS framework seemed only one of many factors of influence in practice‐based training: patient records and other documents were highly influential in daily activities and did not always correspond with CanMEDS roles. Additionally, the position of residents seemed too peripheral to allow them to learn certain aspects of the Health Advocate and Leader roles. Conclusions The CanMEDS framework did not really guide supervisors’ and residents’ practice or interactions. It was not explicitly used as a common language in which to talk about resident performance and roles. Therefore, the extent to which CanMEDS actually helps improve residents’ learning trajectories and conversations between residents and supervisors about residents’ progress remains questionable. This study highlights the fact that the reification of competency frameworks into the complexity of practice‐based learning is not a straightforward exercise.

An innovative approach to identifying learning needs for intrinsic CanMEDS roles in continuing professional development

“…To assess perceived needs, participants were asked to ‘Describe three CPD topic you would like to learn about in the next 12 months’. To identify learning needs that may have arisen from problems encountered in practice, participants were asked to ‘Describe three challenging cases or situations encountered in the past 12 months.’ Given that physicians have varying understanding of the constructs underlying intrinsic competencies[10–13], we refrained from asking respondents to describe learning needs and challenges pertaining to these specific competencies. Rather, our aim was to elicit authentic descriptions of learning needs and challenges encountered in practice across a wide range of specialists.…”

“…Part of the reason for this focus may be related to a lack of clarity regarding such personal and professional competences. Indeed, researches in academic settings have found that physicians do not fully understand the basic constructs underlying intrinsic competencies [10–13]. For example, faculty members often avoid assessing intrinsic CanMEDS roles, particularly those related to collaborator, leader, health advocate, and scholar, which suggests that individuals may not understand the constructs underlying such roles [11].…”

“…While such approaches are certainly an important step in identifying CPD learning needs, the results from such surveys are limited by the extent to which physicians can accurately assess their learning needs. Given that (a) physicians are not particularly effective at self-assessing gaps in their knowledge and abilities[14], and (b) they do not fully understand the constructs relating to intrinsic competencies [10–13], CPD providers need to find alternative approaches to identify learning needs as they pertain to personal and professional competencies. Since many of physicians learning needs arise from problems arising in practice, we were interested in whether physicians’ descriptions of challenges encountered in practice could provide insight into learning needs pertaining to intrinsic competencies.…”

Problematising standards in an era of increasing transparency

“…In this way, assessment practices and standards shape how learners come to think about their practice and how to continually improve it. However, the work conducted by Renting et al 1 shows a lack of integration of the language of the competency framework into daily learning interactions: where 'the names of CanMEDS roles were rarely mentioned outside formal assessment situations'. Therefore, at least in this case, the standards may not be leading to greater transparency of expectations in the day-to-day learning environment for either the trainees or their supervisors.…”

“…In this issue of Medical Education , Renting et al . present an interesting study exploring how CanMEDS roles are ‘given expression in a clinical workplace’ using communities of practice theory.…”