Direct observation in postgraduate medical education: a misleading concept

Chapter 1 comprises the general introduction of this thesis. It explains that the thesis is about one topic, direct observation (DO) in postgraduate medical education (PGME). We have researched this topic from two epistemologically different paradigms, social constructivism and phenomenology. From these different paradigms, we investigated the perspectives of the three groups of participants involved in DO: residents, supervisors, and patients. With ‘DO’ we refer to any situation in which a supervisor is physically present, observing a resident working with a patient. Research on DO was needed since, despite its often underlined importance in PGME, DO appeared hard to incorporate into daily workplace learning in most PGME contexts. In our specific context of general practice (GP) training, this held for DO of technical skills. A first orientation on the literature revealed that DO was mostly seen as instrumental for collecting information on residents’ performance, for purposes of feedback and assessment. Although this instrumental concept of DO may be legitimate in itself, it is a narrow concept when we want to understand what DO, as a social event, is and does in PGME. A broader understanding of DO in PGME, involving the perspectives of all three participants in the situation, will help us make optimum use of situations where a resident, a patient and a supervisor are involved in patient care and medical education. Chapter 2 outlines a study of GP supervisors’ perspectives concerning DO. Chapter 3 describes a similar CGT focus group study, this time with residents. Chapter 4 comprises our study of patients’ experiences in DO situations. We conducted a phenomenological interview study to investigate regularities in pre-reflective experiences of patients in DO situations. Chapter 5 reports on a search that I undertook together with a philosopher. We were both, for different reasons, struggling with how to apply the principles of phenomenology to our research. We engaged in a dialogue with the purpose of formulating an approach for phenomenology in medical education research. The paper presents our journeys and the results of this dialogue where we formulate starting points for an approach to conducting HPE research that has scientific phenomenological integrity and yields practical results. Chapter 6 presents our second phenomenological interview study, focusing on the essences of “what it is like for residents to have a consultation with a patient while the supervisor is observing the resident”. Chapter 7 is a synthesis of our studies and discusses the major findings. In conclusion, direct observation thus far seems a misleading (post-)positivist concept in post-graduate medical education. It is misleading for various reasons: because it delivers questionable data for both feedback and assessment, with all the associated problems and distress; because it may keep supervisors from participating to some extent, attuned to patients’ and residents’ needs; and because it encourages residents and supervisors to isolate DO and assessment from teaching and learning in the workplace. Consequently, this concept of DO may prevent residents and supervisors from making the most of these precious and often scarce occasions. My findings lead me to advocate that on occasions where a resident and a supervisor are together, involved in patient care, they should preferably be WALTzing through PGME.