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Adopting a learning stance

An essential tool for competency development

Marie Giroux, Danielle Saucier, Cynthia Cameron and Christian Rheault
Canadian Family Physician January 2016, 62 (1) e48-e51;
Marie Giroux
Professor in and Director of the Department of Family Medicine and Emergency Medicine at the University of Sherbrooke in Quebec.
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  • For correspondence: Marie.Giroux@USherbrooke.ca
Danielle Saucier
Professor in the Department of Family Medicine and Emergency Medicine at Laval University in Quebec; she helped to design the Triple C curriculum for the College of Family Physicians of Canada.
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Cynthia Cameron
Clinical Professor in the Department of Family Medicine and Emergency Medicine at Laval University and Director of the Lévis Family Practice Unit.
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Christian Rheault
Assistant Professor in the Department of Family Medicine and Emergency Medicine at Laval University and Director of the Family Medicine Residency Program at Laval University.
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Dr Leclaire, a teacher, and Dr William, a resident, have just finished a supervision session during Dr William’s family medicine rotation. As they leave, Dr Leclaire thinks, “I feel like we did a good job with the patients but I’m not so sure I’m helping this resident to progress.” And Dr William thinks, “I believe I did a good job, but I’m not sure that our discussions are going to help me to become a good family physician.”

Does this sound familiar? In the pressurized environment of the clinic, it is often difficult to make the best use of the few moments available for supervision. Where the Triple C curriculum is concerned, giving thought to supervising residents and delivering feedback to make these practices as worthwhile as possible is time well spent.

The literature confirms what we already know from experience to be the most useful strategies to enhance the development of competencies.

  • Learners have to be active. This implies self- regulated learning, self-assessment, speaking up if they need something, and feedback-seeking behaviour.1,2 Yet medical training has traditionally put students on the defensive, encouraging them to show only their strengths.3

  • The supervisor’s primary responsibility is creating an atmosphere conducive to learning. The supervisor acts as a coach, encouraging residents to expand their clinical reasoning and providing them with constructive feedback on a regular basis. A good supervisor adjusts the coaching so that it is relevant to each specific situation; he or she accompanies residents as they progress.4,5

  • Together, they should adopt a collaborative approach, where each recognizes his or her responsibilities in building the relationship.6,7

This type of supervisor-learner interaction during medical training represents a paradigm shift, requiring the dynamic to change at a very profound level. In this article, we describe the concept of an evaluation-focused stance (ES) versus a learning stance (LS) (translated from the French terms position d’évaluation and position d’apprentissage, respectively). We then report on a strategy that 2 Quebec universities have used successfully to encourage both supervisors and learners adopt an LS.

Distinction between ES and LS

The distinction between an ES and an LS was described by Giroux and Girard at the conclusion of a 15-year participatory action research project conducted at the University of Sherbrooke in Quebec.8 The LS and ES represent a series of ideas, emotions, behaviour, and attitudes adopted by learners in their relationships with their supervisors, based on their needs and motivations. It emphasizes the fact that some learners focus on the goal of “becoming a good family physician” while others are mostly driven by the goal of “getting good grades.” One student will see clinical situations as opportunities for real learning, openly talking about the challenges he or she is encountering and looking for answers. By contrast, another student will seek to impress, avoiding situations that could lay bare his or her weaknesses. Through their attitudes, remarks, and supervision strategies, supervisors play a crucial role in shifting the focus to an LS. If they judge a student for the difficulties he or she is encountering, that student might never voice them again.2

Clearly, evaluation is an essential part of medical training—one that coexists with the reality of learning. The LS and ES are part of a continuum, as represented in Figure 1. Students move back and forth along this continuum every day in their interactions with their supervisors. Where they are at any given moment depends on the learning situation, the students (eg, the emotions that the learning situation brings up for the student, past experiences, etc), the attitudes of their supervisors, and the teaching culture in the setting. By the very nature of their role as assessors, preceptors need to take the initiative to create an atmosphere of trust and encourage learners to adopt an LS.

Figure 1.
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Figure 1.

Continuum from an evaluation-focused stance to a learning stance

Many supervisors across Canada try intuitively to encourage their students to adopt a learning stance, to varying degrees of success. Giroux and Girard describe different strategies to help both students and preceptors adopt an LS rather than an ES on a daily basis (Table 1).8

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Table 1.

Ranked supervision strategies that foster adoption of a learning stance: This tool was developed for the family medicine program at the University of Sherbrooke in Quebec in 2003.

Workshop to foster the adoption of an LS

In the 1990s, the University of Sherbrooke introduced a workshop on the LS in an effort to encourage residents to adopt attitudes and strategies for making the most of their residency. Because they were unsure whether their supervisors shared this vision, the residents were initially reluctant to expose themselves and risk bad evaluations. The workshop was re-introduced, this time with the participation of the supervisors.8

The first part of the workshop introduces the notion of LS-ES. Participants are asked to come up with possible strategies, first individually and then in groups. Two actors then simulate a typical supervision session and those watching are instructed to suggest specific strategies favourable to an LS. The actors then play out the scene again, incorporating the suggestions that have been made. The result is a very convincing demonstration of active learning and the LS.

Laval University in Quebec began to use this workshop in 2010 in its efforts to find tools to support competency-based learning. Response to the workshop was so positive that Laval University decided to adopt the concepts and materials that had been developed at the University of Sherbrooke. Since 2013, all of its teaching sites have offered a 2-hour workshop at the beginning of the year that is attended by first- and second-year residents, preceptors, and other professionals involved in teaching.

Each workshop is led by 2 facilitators, 1 of whom is from outside the teaching centre. This facilitator encourages the residents to express themselves, reassuring them that their comments, which are often very emotional, will be treated confidentially. To ensure that the workshop is delivered consistently, a facilitator’s guide has been developed and workshop facilitators meet annually.

The residents and supervisors reported that they really liked the workshop and that it has had lasting and positive effects. Supervisors are more focused on learners’ needs. As one resident put it, “This is the course that has had the most impact on how I behave during supervision. I realized that my supervisors were there to help me. This was the opposite of my experience as a clerk, where I learned to hide certain things.” Second-year residents reported that attending the workshop again at the beginning of their second year was really valuable.

Tips for teaching

The LS involves a reciprocal, explicit responsibility that is shared by the learner and the supervisor; both work together to create conditions conducive to optimal learning. For example, they agree together on a strategy for discussing cases that will meet “real” needs expressed by the learner.

Both benefit when they take an honest look at where they are along the LS-ES continuum. The supervisor also benefits from adopting the LS; a proactive attitude, self-examination, collaboration, open dialogue, and feedback loops are all important aspects of lifelong learning.9 A supervisor’s commitment to ongoing improvement will be a source of inspiration for his or her residents.

For maximum benefit, the LS should be adopted throughout the program. Those in charge in the various rotation settings should ensure that the atmosphere and relationships are conducive to the LS and that learners will be able to trust that they have more to gain by sharing their fears and concerns than by hiding them. The general observation is that the shift results in a healthier, more constructive work environment and learning environment for all.

Tools and resources

The workshop8 can make it easier to apply these concepts on a daily basis and to transform the culture of teaching settings. Based on the experiences of residents and teachers in the field, a list of strategies has been developed for optimizing the LS in clinical supervision (Table 1).8 Supervisors will find that paying attention to the LS will be especially helpful for supervising residents who are struggling.

Adopting the LS and proactive supervision strategies will help you to make the most of what little time you have for supervision. As your clinical load gets heavier and the number of residents grows, these tools might help you to optimize your supervision time.

Conclusion

Encouraging an LS is a useful investment congruent with the Triple C curriculum. We encourage both teachers and residents to explore the concept, and to experiment with the tools. We believe that this concept will aid in the development of competence and that it could prove useful throughout the continuum of medical training.

Notes

Teaching Tips

  • Students who want to take advantage of clinical activities as learning opportunities should openly discuss their challenges and seek answers. Students who are focused on getting good marks will avoid exposing themselves to scrutiny.

  • In the 1990s, the University of Sherbrooke in Quebec introduced a workshop on the learning stance that encouraged residents to adopt attitudes and strategies that would make their residency as meaningful as possible. Since 2013, every teaching setting at Laval University has offered a 2-hour workshop at the beginning of each year. First- and second-year residents, preceptors, and other professionals involved in teaching attend.

  • Supervisors will find that the vocabulary and concepts of the learning stance are particularly useful for working with residents who are struggling.

Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Miriam Lacasse, Teaching Moment Coordinator, at Miriam.Lacasse{at}fmed.ulaval.ca.

Footnotes

  • La version en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de janvier 2016 à la page 86.

  • Competing interests

    None declared

  • Copyright© the College of Family Physicians of Canada

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Canadian Family Physician: 62 (1)
Canadian Family Physician
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Adopting a learning stance
Marie Giroux, Danielle Saucier, Cynthia Cameron, Christian Rheault
Canadian Family Physician Jan 2016, 62 (1) e48-e51;

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Marie Giroux, Danielle Saucier, Cynthia Cameron, Christian Rheault
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