With the advent of postgraduate competency-based medical education (CBME), the preceptor-learner relationship is in the spotlight. The focus on defined outcomes (outcome targets), learner-centric delivery, and direct observation, with an emphasis on formative assessment,1 has demanded a preceptor-learner relationship in which both the preceptor and the learner have key roles.
For preceptors, demonstrating high-quality care and being a good clinical role model are crucial to addressing the importance of patient safety and developing credibility as a teacher. Second, attending to the teaching relationship fosters the learner’s receptivity to feedback2 and sets the stage for negotiating useful goals to advance learning. Third, with the inception of programmatic assessment, contributing to formative (low-stakes) assessment through good-quality feedback3 can create a portrait of the learner advancing to competence. Finally, knowing what roles, habits, or skills residents need to achieve and what outcome targets relevant to a preceptor’s specific context look like are critical. For example, frameworks such as CanMEDS–Family Medicine,4 sentinel habits,5 and skill dimensions6 articulate roles, habits, and skills, respectively, that need to be developed and assessed. Outcome targets, often described in terms of entrustable professional activities, core learning activities, or similar, are broad descriptions of the activities that residents will be able to do by the end of their programs. They reflect their competence to enter and adapt to independent practice.
The role of the resident has shifted from a passive recipient of experience to an active learner engaged in their education and assessment. Specific skills for this role include setting goals, seeking feedback and coaching through direct observation, integrating coaching guidance into practice, reflecting on assessment information, and planning learning to address identified gaps.7 Think of this as a personal quality improvement cycle for professional development.
Preceptors want to teach effectively and avoid confusion. New preceptors may wonder what skills they need and may ask themselves, “Am I ready to teach?” Experienced preceptors face the challenge of the shift to CBME, which requires more direct observation, attention to and skill in giving feedback (coaching), and documentation of low-stakes assessment.
What residents require to engage deeply in their learning and assessment are explicit teaching and modeling of reflective, self-directed, self-regulated learning and to incorporate these skills as part of their professional development.8
Targets for assessment
Programs may have outcome targets (entrustable professional activities, core learning activities, benchmarks) that define the desired performance. It is not possible to assess everything; thus, an assessment is taking an adequate sample of skills to create a picture of the resident’s competence. Specific points for assessment of family medicine residents in Canada are found in the assessment objectives.6 These consist of skill dimensions, articulated as observable behaviour, and priority topics, articulated as key features, which provide both clear targets for assessment in the workplace and descriptive language for preceptors and residents to use for self-assessment and coaching conversations about performance improvement. The Continuous Reflective Assessment for Training (CRAFT)3 model of programmatic assessment defined by the College of Family Physicians of Canada, when taken together with the assessment objectives, provides a high-level blueprint for all residency programs of what to assess and how to assess it. In the CRAFT model, residents are asked to regularly review and reflect on their assessments and, together with a competency coach, engage in planning for further learning.
Both preceptors and residents benefit from a clear understanding of how the direct observations and daily coaching, documented as low-stakes assessment points, contribute both to the reflective processes of a CRAFT-based assessment system and to decisions about the resident’s progress.
Evidence from the literature and best practice
As family physicians we have an excellent foundation for teaching from our clinical roles. This foundation includes finely honed observational skills, good listening skills, and a patient-centred approach. We also recognize “teachable moments.” While these fundamental clinical skills are transferrable to the role of the clinical preceptor in medical education, CBME requires additional skills to become an excellent clinical coach. These are described in the Fundamental Teaching Activities Framework.9
At about every step in the transition to CBME there is the call for faculty development10 to enhance the competence of the clinical coach (who is no longer solely a supervisor or preceptor). This is particularly important for assessment, as decisions on advancement are made through the assessments of multiple preceptors and are only as good as the quality of the documented assessment information.
Brief, direct observation of residents in the workplace by preceptors is widely recognized as the best assessment method.11 This approach fits into a busy clinical workplace and, when observations are aggregated from multiple observers over time, is a trustworthy indicator of resident competence.12
The Fundamental Teaching Activities in Family Medicine9 describes the skills of the day-to-day clinical supervisor or clinical coach as follows:
explicitly embodies the roles, attitudes, and competencies of family physicians in clinical work,
promotes and stimulates clinical reasoning and problem solving,
gives timely learner-centred and constructive feedback,
uses program assessment tools to document observed learner performance according to the level of training, and
uses reflective processes to refine clinical supervision.
Both preceptors (now clinical coaches) and residents need to know the relevant abilities and skills that are expected at the end of training. To inform progress decisions, they need to know how to enact a learning plan, what the best points to assess are (eg, 6 skill dimensions,6 observable behaviour, priority topics, key features), and when best to assess. These skills and knowledge need to be specifically developed with faculty and not left to chance. What follows are some tips and resources to fill this gap.
Tools and resources
Many programs assess the 6 skill dimensions6; the booklets excerpted from the assessment objectives on professionalism,13 selectivity,14 and communication15 provide a practical way for clinical teachers and residents to talk about these specific skills and what is meant by each.
Direct use of any of the 106 priority topics (found in the assessment objectives6) and their associated key features can be helpful, as the key features can allow the observer to focus on the most important aspect to assess and where in the clinical encounter one is most likely to see the specific skill in action. All are tagged with the most relevant skill dimensions, such as clinical reasoning or selectivity.
Likewise, for clinical teachers and faculty developers there are resources for developing the skills of direct observation, having useful feedback conversations, reflecting on one’s own teaching, and fostering clinical reasoning and problem solving. The College of Family Physicians of Canada Faculty Development Resource Repository (https://communities.cfpc.ca/committees~5/repository) is one such resource.
Conclusion
The assessment objectives6 provide useful, practical language to help clinical teachers and residents work together. The Fundamental Teaching Activities in Family Medicine9 provides a description of the clinical coaching skills needed to develop and enhance a resident’s clinical skills and professional development and model the reflective processes found in CRAFT. Skillful coaching and assessment are also critical to providing quality assessment information for “higher-stakes” progress decisions. Use these readily available tools to support your coaching in the workplace and to provide what residents both need and want.
Notes
Teaching tips
▸ Ask residents for their learning goals.
▸ Plan to observe them directly when it is relevant to their goal.
▸ Ask them if there are specific priority topics or skills they are seeking to improve.
▸ Consider using the key features of the priority topic directly to guide your assessment and to supplement a “coaching conversation.”
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 Viola Antao, Teaching Moment Coordinator, at viola.antao{at}utoronto.ca.
Footnotes
Competing interests
None declared
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de juillet 2022 à la page e227.
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