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Academic Medicine:
doi: 10.1097/01.ACM.0000232422.81299.b7
Learning Issues

Learning in Practice: Experiences and Perceptions of High-Scoring Physicians

Sargeant, Joan BN, MEd; Mann, Karen BN, MSc, PhD; Sinclair, Douglas MD; Ferrier, Suzanne MSc; Muirhead, Philip MD; van der Vleuten, Cees PhD; Metsemakers, Job MD, PhD

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Author Information

Ms. Sargeant is director of program development and evaluation, Office of Continuing Medical Education, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia.

Dr. Mann is director, Division of Medical Education, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia.

Dr. Sinclair is associate dean, Continuing Medical Education, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia.

Dr. Ferrier is research associate, Continuing Medical Education, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia.

Dr. Muirhead is a family physician, Musquodoboit Family Practice, Nova Scotia.

Dr. van der Vleuten is chair, Department of Educational Development and Research, University of Maastricht, The Netherlands.

Dr. Metsemakers is chair, Department of General Practice, University of Maastricht, The Netherlands.

Correspondence should be addressed to Ms. Sargeant, Office of Continuing Medical Education, Faculty of Medicine, Dalhousie University, 5849 University Avenue, Halifax, NS B3H 4H7; telephone: (902) 494-1995; e-mail: (joan.sargeant@dal.ca).

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Abstract

Purpose: To increase understanding of informal learning in practice (e.g., consulting with colleagues, reading journals) through exploring the experiences and perceptions of physicians perceived to be performing well. Objectives were to find out how physicians learned in practice and maintained their competence, and how they learned about the communication skills domain specifically.

Method: Of 142 family physicians participating in a formal multisource feedback (360-degree) formative assessment, 25 receiving high scores were invited to participate in interviews conducted in 2003 at Dalhousie University Faculty of Medicine. Twelve responded. Interviews were 1.5 hours each, recorded, transcribed, and analyzed by the research team using accepted qualitative procedures.

Results: While formal learning appeared important to most, informal learning, especially through patients and colleagues, appeared to be fundamental. The physicians appeared to learn intentionally from practice and work experiences, and reflection appeared integral to learning and monitoring the impact of learning. Two findings were surprising: participants’ conceptions of competence and perceptions that communication skills were innate rather than learned.

Conclusions: These physicians’ ways of intentional learning from practice concur with current models of informal learning. However, informal learning is largely unrecognized by formal institutions. Additionally, the physicians did not in general share notions of professional competence held by educators and others in authority. These findings suggest the need to make implicit content and learning processes more explicit. Additional research areas include exploring whether physicians across the range of performance levels demonstrate similar processes of reflective learning.

Society expects physicians to remain competent throughout their careers. To achieve this, professional, educational and regulatory bodies expect them to be lifelong learners capable of assessing their own knowledge, skills and performance to direct their continued learning.1–6 While much of their learning involves formal continuing medical education (CME) programs (e.g., lectures, workshops), it also includes informal learning in practice (e.g., consultation with colleagues, reading journals). Few studies have explored this second form of learning and the informal processes physicians use for assessing, responding to, and monitoring their learning needs.

Physicians in practice learn formally through structured, sanctioned activities and informally through other activities and experiences. An extensive study of physician change and learning reported diverse ways of learning and their relation to specific practice changes. When making changes related to professional competence, physicians reported more frequently using formal learning resources than informal ones, but participation in formal CME programs was usually only one of several methods. They also valued informal learning from colleagues.7

Theories of learning through work experience and informal learning suggest that reflecting upon experiences appears central to learning.8–14 It is suggested that reflection functions as a mediator between prior knowledge or skill and observation or experience.14 Building upon this concept, Simons et al.15 suggest two ways to learn beyond formal or structured learning: experiential learning, in which there are no specific preplanned goals and learning is a side effect of one’s activities, and action learning, where learning is central, planned and self-directed by the learner. Similarly, Eraut16 describing informal learning in the workplace (e.g., by observing others or through “trial and error”) discriminates among three types of learning: implicit learning, which occurs unconsciously, reactive, or opportunistic, learning, which is more or less spontaneous, and deliberative learning, which is self-directed, planned, organized and has definite goals.

However, learning through experience and informal learning tend to be less visible and frequently unacknowledged as learning.17,18 While formal learning tends to be “explicit” with knowledge readily visible, articulated, communicated and hence more accessible for learning, informal learning and learning from experience are more frequently “tacit,” with knowledge not explicitly stated, often invisible to the learner and others, and hence elusive to communicate and learn.19 These distinctions are important to learning directed toward gaining professional competence. Medical competence is a multidimensional construct consisting of four broad domains (cognitive–technical, integrative, interpersonal, and affective, or moral), each requiring different kinds of knowledge, skills, and attitudes.20 While explicit knowledge visible in formal medical education is conventionally scientific, evidence-based and quantifiable, tacit knowledge, inherent within the integrative, interpersonal and affective domains of competence, tends to be less tangible. Because it is gained informally through observation and practice, sometimes even unconsciously, it is also less visible. These characteristics of informal learning have implications for continued learning.

We undertook this qualitative study of family physicians who had received high scores in a formal multisource feedback (360-degree) formative assessment addressing clinical, interpersonal, and professional domains of competence.21 Our purpose was to increase understanding of learning and maintaining competence in practice through exploring these physicians’ experiences and perceptions. Our rationale for selecting this group was the assumption that physicians rated highly by their medical colleagues, co-workers and patients (i.e., physicians seen to be performing well) could offer insights into successful approaches for continued learning and maintaining competence. Our specific objectives were to explore how these physicians (1) learned in practice and maintained their competence, and (2) learned about the communication skills domain specifically.

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Method

Study background

In 2002, the College of Physicians and Surgeons of Nova Scotia conducted a pilot study of multisource feedback (MSF) for family physicians using the standardized College of Physicians and Surgeons of Alberta Physician Achievement Review program, a formative process.4,5 Following program guidelines, 142 volunteer physicians identified reviewers in two groups (eight medical colleagues, eight co-workers) and randomly selected 25 patient reviewers. Performance domains included patient communication, team communication, professionalism, clinical performance, and office management. The reviewers rated the physician participants on multiple questionnaire items for each domain, and each of the physicians completed a self-assessment. Participants received their feedback in mailed confidential reports that presented their individual and aggregate mean scores for each item and domain. Scores above the 90th percentile received “commendation” flags, and below the tenth percentile, “information” flags.

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Study design

Using open-ended questions, we interviewed high-scoring physicians who had participated in the pilot study described above. Our goal was to explore their experiences with and perceptions about learning in practice. Open-ended questions enable participants to describe experiences and perceptions meaningful to them and to explore related meanings and interpretations.22 The questions inquired about the nature of their medical practices and their communication patterns with patients, colleagues and co-workers; stimuli that made them realize they needed to learn more about a specific topic; approaches they generally used to meet their learning needs; and their perceptions of the above processes.

We sent invitation letters to the 25 of the 142 volunteer physicians receiving the highest mean domain scores from all three reviewer groups, while not receiving an information flag for any domain. Twelve accepted the invitation. They received the study questions beforehand to encourage reflection. One of us (SF) conducted the interviews, consulting with others (JS, KM, DS, PM) following each interview, and another (JS) assisted with one interview. Each interview was one to 1.5 hours long; they were audio-recorded and transcribed. The study was funded by the Nova Scotia Health Research Foundation, approved by the Dalhousie University Research Ethics Board and conducted in 2003 by Dalhousie University Office of Continuing Medical Education.

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Data analysis

We conducted the analysis as a team using standard analytical procedures for qualitative data. First, using a content analysis approach, we individually reviewed and coded two transcripts, then discussed these and developed a coding framework. We used this framework to individually analyze remaining transcripts, and met regularly to discuss emerging themes, resolve differing interpretations, and revise the coding structure as required. Second, one of us (JS) then compared and contrasted data within and among participants and themes, to determine and interpret relationships and confirm dominant themes.22 She conducted this work in an iterative manner in consultation with the research team (KM, DS, SF, PM, CV, JM).

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Results

The participating physicians were ten men and two women, ranging in age from 41–60 years with an average of 25 years in practice. Five practiced in communities of over 50,000 (considered urban) and 7 in smaller communities (considered rural). Compared with the Nova Scotia family physician population, the sample underrepresented women, overrepresented rural physicians, and its members had been in practice slightly longer. As a group they described busy and multifaceted practices, appeared passionate about their practices and patients, and appeared to strive to maintain a balance of professional and personal activities.

Our findings fall into two general groupings: participants’ general approaches to learning and maintaining competence in practice, and their learning specifically about the communication skills, domain.

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General approaches to learning and maintaining competence

While formal learning appeared important to most, informal learning especially through patients and colleagues, appeared fundamental. These physicians were stimulated to learn by many factors and used multiple resources and approaches. Formal CME programs were only one resource, and for some physicians, these appeared less useful than self-directed informal activities. Informal learning approaches were individualized and diverse, and usually linked to the experience of the physician’s practice. These physicians appeared highly motivated to learn and to be curious. They demonstrated three common important behaviors:

1. They were reflective (e.g., considered their practices in a thoughtful manner), self-aware (e.g., described approaches they used to inform themselves of their progress and learning needs), self-directed (e.g., identified ways to improve) learners. All described reflecting upon their practices and their knowledge, skills, and attitudes, and monitoring their learning needs.If you’ve a very busy clinician you know where you’re a little unsure of yourself, you know where you might be just a little bit shaky sometimes, that’s the kind of stuff you look for, and I think the awareness comes out of your own work. You don’t need somebody else to tell you that. (From physician 9, in a rural practice.)

2. They were stimulated by and learned from patients. Patients served as both stimuli for learning and sources of learning.But you know, just being involved with the patient from diagnosis through the whole process, from the presentation through the whole process of diagnosis and treatment, I think that’s the learning experience. It stimulates me, if I have a certain case, to go read about it, so that I can manage it. So I guess that outside of the structured CME, that’s how I deal with it [learning]. (From physician 10, in a rural practice.)

3. They were stimulated by and learned from others, especially medical colleagues. All identified the value of this informal learning process.I suppose that’s one of the advantages of small town practice. I’m interacting on a daily basis with colleagues, family doctors, consultants; I do hospital inpatient work, so I’m interacting daily. It’s a very valuable aspect of practice and really CME, that you wouldn’t have say in “X” town, where you’re more office-based. (From physician 8, in a rural practice.)

Physicians without hospital privileges told of more limited, yet valuable, face-to-face interactions with colleagues but also described other forms of communication, such as consultants’ letters, reports, and phone conversations as valued learning opportunities.

In addition to learning from patients and colleagues, all described learning from medical journals, and, to varying degrees, from literature and Internet searches, teaching students and peers, making house calls, other health professionals and staff, and self-initiated clinical experiences.

Within these diverse and rich approaches, two learning patterns emerged. The first appeared to be spontaneous learning, learning in response to immediate stimuli that arise within the context of their practices. All participants described this kind of learning:

We like to be confident about our patients and every now and then you see a problem patient you start to realize, whoops, time to brush up a little bit. … You realize that 90% of health care in the office is repetitious, things that we see day in, day out. But you know, if I see something very interesting, very different, I go and start reading and look up colleagues down the hall and also the other specialists in town. (From physician 11, in an urban practice.)

When they encountered a question—either one they posed to themselves or that someone asked them—that they did not know the answer to, they sought the answers on their own.

The second approach, exhibited by about two thirds of the participants, was distinct from the first as it involved preplanning, organization and commitment over time. They described setting learning goals and systematically planning and engaging in diverse learning interventions to meet these goals. They also reflected openly about how they learned and the kinds of activities that worked for them, as illustrated below.

I thought about how I learn and I’m thinking of changing a bit, about how I’m doing it just to try to learn differently. Lectures are good for me in the sense of getting an overview, but it doesn’t stick with me very long, and even these problem-based small-group learning meetings, the method that we’re using, I don’t think it’s quite meeting my needs … I think that what sticks with me the best is what I do in practice. I see a problem and I have to go to the books and figure out what to do for somebody. If I get a similar problem I’ll often go back to that person’s chart and try to figure out what I did. (From physician 5, in an urban practice.)

I’ve identified how I learn well, and I’ve used little tricks to keep as sharp as I can. If you take the premise that really, by and large, you’re not that bright, you will have a very healthy approach to the problem, the patient, and your ongoing education. It’s very difficult to keep up, so I have to have sneaky ways to do it and I use students and specialists and every other tool I can find. (From physician 12, in a rural practice.)

Some of the tricks he used were researching a topic and posting the notes on his office wall for visual reinforcement, working with students to research topics, and designing courses with specialists to teach to his peers.

About half of the physicians expressed keen interest in specific clinical areas, and as part of their comprehensive learning plan, described self-directed, prearranged, regular activities in their area of interest (e.g., sports surgery, emergency medicine, palliative care, counseling, serving native populations). Several took it upon themselves to arrange clinical or other experiences to advance this learning. One observed that his spending time assisting in the operating room actually enabled him to meet several learning needs:

So, I mean, you’re not there to learn the surgical technique and you’re not there to be the star of the O.R. You’re just really there as [part of] the lowest echelon, a person to help out, but they need an extra set of hands. So I love it because it feeds what little interest I have in surgery without having to be a surgeon. And it gets me in to see all the surgeons and I get to pester them with questions. (From physician 4, in an urban practice.)

This last quote, in fact, illuminates several characteristics of these learners—their ability to plan learning interventions, their curiosity, their self-awareness, and their skill in opportunistic learning.

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Learning specifically about the communication skills domain

When asked about their approaches to learning, as described above, participants described learning activities related to traditionally defined clinical competence only, despite having been evaluated on their competence in other domains. The exception was one whose particular interest was counseling youth. The others mentioned learning in the communication skills and other domains only when specifically asked.

In the rest of this section, we describe these physicians’ communication practices with both their patients and members of the health care team, and their perceptions of and experiences with learning and teaching these skills.

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Descriptions of communication practices.

In describing their communication practices, they gave rich and detailed descriptions of their interactions with patients and the health care team. These appeared to demonstrate characteristics of effective communication.23 It was also apparent that communication was key to their successful practices:

Communication with patients. Attending to the patient, being present, taking time, and showing interest in patients and their families as people were common themes.

I have one patient in the world at a time and it’s the one in front of me. (From physician 9, in a rural practice.)

They [patients] like to know that you at least understand what they’re going through and understand where they’re coming from, even though they may not be empowered or desire to change at that point. (From physician 2, in a rural practice.)

I’m not in a rush with my patients … so I’m barely even caught up on what’s going on in their lives or how their kid’s hockey tournament went, when other people [physicians] were moving on to their next patient. (From physician 4, in an urban practice.)

Communication with team members. They described rich, respectful, egalitarian, relationships with others. For example, with office staff:

We’ve come to know each other so well that we work as a family and it’s a comfortable thing. (From physician 11, in an urban practice.)

With other members of the health care team:

The practice of modern medicine is a team job. These are all people who have expertise I don’t have. Patient care works best when everybody in the team gets to do their job and do it well. (From physician 9, in a rural practice.)

With specialist physicians:

You have certain people that you’re referring to and the reason you select those is … you have great respect for them, they do a good job, they’re accessible to me, and I think they have respect for my abilities. They get to know what your limitations and what your abilities are and you get a very good working relationship with them. And that’s what I have – a group of specialists that I use all the time and they know me and I know them and it works well. (From physician 7, in a rural practice.)

Respect was a common thread emphasized in descriptions about communication with team members.

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Perceptions about teaching and learning communication skills.

Although they described their approaches to patients and others in terms which reflect high-quality patient and team communication (attentive, compassionate, interested, respectful),23 about half expressed skepticism about the ability to teach and learn these skills. These considered communication skills “a personality trait” (physician 2, rural practice), “either you have it or you don’t” (physician 5, urban practice; physician 8, rural practice), or “a lot of it has to do with what you’re like as a person” (physician 7, rural practice).

They believed that physicians’ attitudes and awareness influenced their communication with others:

If you don’t think you need to put the effort in, well then you’re not going to communicate very well. Most physicians think, “I’m a busy doctor and as long as I look after patients clinically well, that’s all I need to worry about, so I don’t need to get any help in that [communication] area.” (From physician 6, in a rural practice.)

These guys that have poor communication skills, I don’t know how well they recognize it or whether they care. (From physician 8, in a rural practice.)

A lot of it has to do with respect … how do you learn that sort of thing? How do you teach that sort of thing? I don’t know. (From physician 7, in a rural practice.)

Another physician (physician 10, rural practice) believed that “among physicians, there’s a big need to communicate better … I think we’re pretty egotistical and so we don’t always receive criticism easily and I think we all have room to improve in that regard.”

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Experiences in learning.

The majority, when asked about learning about communication skills, said they had learned through experience:

It’s just 20 years of practice and if I haven’t got it right now I’ll never get it right! (From physician 10, in a rural practice.)

It’s a learned technique [communicating clearly with elderly patients] that takes years to learn from experience, for sure. (From physician 7, in a rural practice.)

A minority described learning these skills in a structured way. One referred to learning them in his medical training and practicing them every day (physician 4, urban practice), and another, whose clinical focus was counseling adolescents, intentionally sought out CME courses that improved her communication skills (physician 3, urban practice). Only two others were aware of CME courses in communication skills. However, when asked to reflect upon how communication skills might be taught, several provided insightful suggestions: mentorships with physicians who were good communicators, providing “tips from the masters,” small-group learning, and, for team communication, interprofessional courses.

In summary, these physicians demonstrated respect and attentiveness in communication with others and articulated the importance of these attributes. However, they perceived barriers to teaching and learning them, and a number appeared to regard communication skills as reflecting personality traits rather than learnable skills.

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Conclusions and Discussion

This study of high-scoring family physicians was undertaken to explore their experiences in and perceptions of how they continued to learn and how they maintained their competence. We believe that it contributes insights in three areas: learning in practice, notions of professional competence, and perceptions about learning communication skills.

First, while formal or structured learning appeared important to most, informal learning especially through patients and colleagues, appeared fundamental to their maintaining professional competence. This contrasts with an earlier finding that physicians more frequently used formal learning resources in relation to practice change,7 but supports findings that physicians’ learned in multiple ways, of which formal CME was only one, and that they valued learning from colleagues.

Notably, this learning from practice and work experiences appeared intentional. All physicians appeared reflective, reflecting upon their practice and patients, skills and knowledge, interactions with patients and others, and strengths and weaknesses. Reflection appeared integral to their learning and to monitoring its impact.

All participants described learning characteristic of Simons’ experiential learning, where there are no explicit learning goals other than to learn through experience, and learning occurs as a side effect of one’s activities.15 They also seemed to reflect Eraut’s reactive learning, which happens nearly spontaneously in the normal course of work.16 In both cases, specific learning is unplanned but there is a conscious intent to learn from experience through reflecting upon it. Two-thirds of the group appeared to also demonstrate a planned, structured approach to their learning, reflective of Simons’ active learning and Eraut’s deliberative learning, where learning from practice is a conscious, self-directed, planned activity consisting of goal-setting, scheduling, and organizing.

Findings about the respondents’ notions of professional competence and teaching and learning communication skills were surprising. When asked to describe how they generally learned and maintained their competence, 11 of the 12 described their learning about traditional “clinical” competence only. They did not consider learning in other domains until specifically asked about each. Regarding communication skills, these high-scoring physicians articulated and appeared to demonstrate that communication with patients and communication with others were core professional skills. Yet, over half did not believe that these skills could be taught and learned and instead considered them personality traits.

We explored these responses on two levels. Pragmatically, the introduction of instruction in communication skills and other nontraditional domains into formal medical curricula is relatively recent. Most of these physicians, averaging 25 years in practice, would have received limited formal instruction in medical school in the basic knowledge and skills underpinning competency in these domains.

On the perceptual level, the absence of these domains from the formal curriculum during the respondents’ medical education made them less visible, reinforcing the perception that they were less valued.17,19 Consequently, it is less likely that they were a part of the responding physicians’ conscious awareness of what constitutes professional competence. Considering communication skills in particular, this assumption would support the participants’ view that how one communicates is primarily part of one’s personality. It is unlikely that these physicians received explicit instruction in their medical educations that would lead them to think otherwise.

Implicit, or tacit, learning from practice and from experiences can be unconscious.16,19 For these physicians, learning communication skills could have been unconscious, contributing to perceptions that these could not be explicitly taught but were learned “through experience.” Interestingly, these views reflect those expressed by Balint when he observed 50 years ago that communication skills were learned through “experience and common sense.”24

Limitations of this study include the volunteer nature of participants and their location within only one geographical area (a single Canadian province). Although the study group was small, the data appeared saturated, as no new themes arose with the addition of the last three interviews. Additionally, interviews were conducted by staff of the local academic CME program, and it is possible that this and other factors moderated physicians’ responses to reflect social desirability. However, we think this unlikely based on their sincerity and their enthusiasm for and commitment to their practices and learning—conveyed throughout the interviews—and their rich descriptions of their practices.

What are the implications of these findings? Foremost seems to be the need to make the implicit skills, knowledge, attitudes, and processes in medical practice, education, and assessment more explicit—in short, to make the invisible visible. This is important because it may enable physicians who are not using these approaches to learn them and use them, and help educators to better design programs and coach learners at all levels of the curriculum. It includes both content and process. Regarding content, our findings suggest that physicians in practice may not share notions of professional competence held by educators and others who define them. Making these constructs more explicit, as institutions are now striving to do through curricula in communication skills and professionalism, for example, will aid in physicians’ sharing a vision of professional competence and its domains. This would help physicians understand professional competence and its domains and foster physicians’ capacities to articulate, learn, and self-assess, all necessary steps on the road to literacy and mastery in professional competence.

Regarding the process of learning, making the invisible visible refers to the reflective, informal, and largely unrecognized ways of learning from practice described by these physicians and others.6 Explicitly acknowledging these useful strategies would formally reinforce their value as learning activities and increase their accessibility (e.g., by making explicit the skills inherent in practice reflection and self-directed learning17–19).

Implications for further research include exploring effective ways of implementing the above; that is, of making the implicit professional content and learning processes more accessible to physicians and more formally recognized by educational, professional and regulatory institutions. A potentially important line of inquiry concerns exploration of the use of self-directed reflective intentional learning from practice among family physicians across the range of performance, to answer the question, “Is this learning approach used by physicians at all levels of performance?” At this time we do not know the answer to that question. We are currently studying a diverse group of physicians to explore it.

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References

1 CanMEDS project (http://rcpsc.medical.org/canmeds/index.php). Accessed 4 April 2006. Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, 1996.

2 Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. General competencies. (http://www.acgme.org/outcome/comp/compFull.asp). Accessed 4 April 2006. Accreditation Council for Graduate Medical Education, Chicago, Illinois, 2001.

3 Miller SH. American Board of Medical Specialties and Repositioning for Excellence in Lifelong Learning: Maintenance of Certification. J Contin Educ Health Prof. 2005;25:151–56.

4 General Medical Council (GMC). Good Medical Practice. London: GMC, 2001.

5 College of Physicians and Surgeons of Alberta, Physician Achievement Review Program (http://www.par-program.org/). Accessed 4 April 2006. Pivotal Research Inc., Edmonton, Alberta, 2005.

6 Nova Scotia Physician Achievement Review (NSPAR) Program (http://www.nspar.ca/). Accessed 4 April 2006. College of Physician and Surgeons of Nova Scotia, Halifax, Nova Scotia. 2005.

7 Fox R, Mazmanian P, Putnam W (eds). Changing and Learning in the Lives of Physicians. New York: Praeger Publishers, 1989.

8 Dewey J. Experience and Nature. 1932 ed. New York: Dover, 1958.

9 Tough A. The Adults’ Learning Projects. Toronto: Ontario Institute for Studies in Education, 1979.

10 Kolb D. Experiential Learning. Englewood Cliffs, NJ: Prentice-Hall, 1984.

11 Usher R. Beyond the anecdotal: adult learning and the use of experience. Stud Educ Adults.1985;17(1):59–74.

12 Schon DA. Educating the Reflective Practitioner. San Francisco: Jossey-Bass Publishers, 1987.

13 Boud D, Walker D. Experience and Learning: Reflection at Work. Deakin University, Australia: Deakin University Press, 1991.

14 van de Wiel M, Szegedi K, Weggeman M. Professional learning: deliberate attempts at developing expertise. In: Boshuizen H, Bromme R, Gruber H (eds). Professional Learning: Gaps and Transitions on the Way from Novice to Expert. Dordrecht, NL: Kluwer Academic Publishers, 2004.

15 Simons R-J, van der Linden J, Duffy T. New learning: three ways to learn in a new balance. In: Simons R-J, van der Linden J, Duffy T (eds). New Learning. Dordrecht, NL: Kluwer Academic Publishers, 2000.

16 Eraut M. Informal learning in the workplace. Stud Contin Educ. 2004;26:247–73.

17 Boud D, Middleton H. Learning from others at work: communities of practice and informal learning. J Workplace Learn. 2003;15:194–202.

18 Boud D, Solomon N. “I don’t think I am a learner”: acts of naming learners at work. J Workplace Learn. 2003; 15:326–31.

19 Epstein R. Mindful practice. JAMA. 1999;282:833–39.

20 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226–35.

21 Sargeant JM, Mann KV, Ferrier SN, et al. Responses of rural family physicians and their colleague and coworker raters to a multi-source feedback process: a pilot study. Acad Med. 2003;78(10 suppl):S42–S44.

22 Rice PL, Ezzy D. Qualitative Research Methods. Victoria, Australia: Oxford University Press, 2000.

23 Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. Oxon: Radcliff Medical Press, 1998.

24 Balint M. The Doctor, His Patient and the Illness. 2nd edition. London: Pitman Paperbacks, 1968.

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