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#KeyLIMEPodcast 198: There is no more difficult art to acquire than the art of observation… (W Osler)

What are the manifestations, meanings and effects of direct observation in developing postgraduate training relationships? Read on, and check out the podcast here (or on iTunes!)


KeyLIME Session 198:

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Rietmeijer et al,. Patterns of direct observation and their impact during residency: general practice supervisors’ Med Educ.2018 Jul 24. [Epub ahead of print]


Reviewer: Linda Snell (@LindaSMedEd)


Direct observation – DO – is when the supervisor is physically present, watching the resident providing patient care, and is seen as an important means of gathering information on the performance of the resident, for purposes of supervision, feedback, assessment and entrustment, and key in competency-based medical education. But it does not necessarily fit with patient care in PGME, and may be infrequent and poorly done.

Why? Fear of assessment affects resident  performance when observed directly; workplace culture like  efficiency and residents’ autonomy may conflict with asking or offering DO.

In the old days it was a two way street – residents observed the master and vice versa; currently it is one way.

DO is a complex phenomenon with education (assessment, entrustment), psychological and cultural components.


Research question: What are the manifestations, meanings and effects of DO in developing postgraduate training relationships?

Authors chose to focus on understanding the perspective of clinical supervisors as they play a pivotal role in the DO in clinical education / practice. In the Netherlands GP residents PGY1 and 3 are directly supervised for the year by an experienced, faculty developed supervisor.

Key Points on Method

Qualitative study using focus groups with supervisors of general practice (GP) residents, to discuss the manifestations, meanings and effects of DO of technical skills. Chose technical as it is done less frequently than comm skills.

Convenience + purposive (to get 1st and 3rd year supervisor) sample; each group interviewed separately.

Theoretical sufficiency reached after 4 focus groups, 28 participants.

Interview guide =   manifestations of DO of technical skills (How does DO occur? Who is present? Who does what? etc.); the supervisor’s thoughts and feelings with regard to observing his or her resident; the assumed thoughts and feelings of residents with regard to being observed by a supervisor; the importance and benefits of DO; the initiative to engage in DO, and the influence of the relationship between supervisor and resident on DO and vice versa.

They did not specifically define ‘technical skills’.

Member checking by sending summaries to FG participants **

Analysis – constant comparison in constructivist grounded theory, iterative coding and theme development, eventually a model developed.

Key Outcomes

15 1st year, 13 3rd year supervisors; latter slightly older and more experienced.

DO equated with not observing directly, but instead providing nearby, immediately available supervision.  Thought to be important gives the residents space to self-regulate their learning, gain self-confidence and develop their own working style. DO balanced with ‘nearby supervision’.

Technical skills included procedures, but physical exam +/- history only for some.

Patterns of DO:

  1. initial planned (bidirectional) DO sessions – watch me, I watch you and assess and coach
  2. resident-initiated ad hoc DO – ask the supervisor for help/guidance; supervisors expect this to some extent
  3. supervisor-initiated ad hoc DO – supervisor found easier to do for new skills
  4. continued planned (bidirectional) DO sessions – more formal organized pattern #1 on a continuing basis

All 4 have a positive effect on the relationship, 2&3 also have a negative effect if too infrequent or skills too basic.

Patterns defined by stage of the developing relationship,  who initiated DO,  what was observed how it was done, either ad hoc or as a planned session, either bi- or unidirectionally.

Relate to effects, like becoming acquainted, checking, teaching, trusting, mistrusting, giving space, loss of time, falling short, emotional discomfort and pleasure, all of which related to the training relationship, patient safety or residents’ learning. Clarity on the part of supervisors and residents regarding the intention with which DO was offered or requested appeared to be especially important in the ad hoc patterns of DO. Supervisors differed in their repertoires for dealing with situations where there was a clash between their role as teacher, residents’ independence and patient safety.

Direct observation at the beginning of the training relationship as an opportunity to combine familiarizing themselves with residents’ abilities with sharing expectations and preferences.

Initial planned DO sessions, supervisors observed their residents and residents observed them too; demonstrating and discussing technical skills, and demonstrating how they deal with uncertainty and time pressure.

Difficulties of ad hoc DO – hesitance to initiate, conflicted staff and residents.

Implications for workplace learning – need to share responsibility for initiating DO and discuss how to make it work best, planned bidirectional good practice.

Key Conclusions

The authors conclude…DO meant much more than gathering information for purposes of feedback and assessment. They found four DO patterns that illustrate how DO helps to shape the resident–supervisor relationship, and can contribute to patient safety and residents’ learning.

Tensions seemed to relate mostly to the ad hoc patterns of DO, whereas planned bidirectional DO sessions might prevent many of these.

Efforts to achieve more frequent DO for purposes of feedback and assessment have to take different patterns of DO into account. An open discussion between supervisors and residents on how DO can work best for both in different phases of the relationship seems a good starting point.

Spare Keys – other take home points for clinician educators

Studied only supervisor perceptions, and technical skills (not further defined). How generalizable is this beyond specialty, setting, institution?

Nicely link in literature on this – Watling, Hatala et al

There is no more difficult art to acquire than the art of observation…and for some men it is quite as difficult to record an observation in brief and plain language. W Osler


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