Wenrich, Marjorie D. MPH; Jackson, Molly B. MD; Ajam, Kamal S. MD; Wolfhagen, Ineke H. PhD; Ramsey, Paul G. MD; Scherpbier, Albert J. MD
Many studies have documented the decline in physicians' knowledge base and clinical skills over time due to the rapid growth of medical knowledge, fewer opportunities to practice basic skills later in physicians' careers, and other factors.1–5 Despite the strong need and call for lifelong learning and extensive use of continuing medical education by physicians,6–8 effective methods to implement lifelong learning remain elusive thanks to practice-related barriers and a lack of understanding of factors influencing learning.
Formal learning through time-limited, classroom-based courses shows limited effectiveness in improving practice outcomes.9,10 However, formal learning remains the dominant approach to lifelong learning.8 Less attention has focused on informal learning, which is frequently contextual, based in the learner's environment, and controlled by learners.11 Eraut12 describes three levels of intention in informal learning: (1) implicit learning, in which knowledge acquisition lacks both conscious attempts to learn and explicit knowledge of what was learned, (2) reactive, or opportunistic, learning, which is intentional but occurs spontaneously in the middle of an action, and (3) deliberative learning, which is intentional and has learning goals and planned time for acquiring new knowledge and engagement.
Deliberate practice—extensive, sustained practice of necessary skills, such as occurs during undergraduate and residency training—is essential to developing and maintaining expertise, yet data indicate that deliberate practice after medical school and residency training is rare.13 The motivation necessary to move beyond a performance “plateau” among practicing physicians may be introduced through experiencing doubt, uncertainty, or an emerging difficult event or problem,14 resulting in the commencement of a reflective process first characterized by Dewey.15 For some, this reflective process may initiate a learning process.
One potential arena for informal and contextual learning is the teaching environment,16 where teaching can gain added value if it initiates learning or provides contextual lifelong learning. The relevance of bedside teaching as a distinctive method for maintaining or advancing physicians' clinical skills has received little attention. Despite recommendations that teachers acquire bedside teaching skills and reinforce and update their clinical skills,17 physicians' discomfort with their skills and the increasing reliance on laboratory tests, imaging, and consultative services to diagnose away from the bedside may deter physicians from undertaking bedside training.18 On the other hand, if bedside teaching improves physicians' own skills or stimulates learning, then it has advantages for students in skills instruction, for physicians and other members of the health care team in improving physicians' skills, and for patients in improved quality of care.
Several studies have examined how teaching preclinical medical students in ambulatory settings affects community preceptors. Teachers reported increased morale, skills improvement, and positive practice infrastructure changes.19,20 Skills improvements were attributed to increased reading and reflection, receiving information and challenging questions from students, and increased time with patients. Students' questions made teachers observant of their work routines and patient management, elucidated shortcomings and knowledge gaps, and stimulated keeping up-to-date. Such preceptorships, however, frequently occur in outpatient settings. To our knowledge, no work has closely examined the impact of teaching medical students in inpatient settings on faculty's clinical skills.
In this qualitative study, we assessed the impact on full-time faculty's own clinical skills and practices of sustained clinical skills bedside teaching with preclerkship students. Our research question was based on interviews with faculty over the initial five years of a bedside teaching program and asked how faculty perceive the impact of bedside teaching on their own clinical knowledge, skills, and attitudes.
At the University of Washington School of Medicine, some faculty train small groups of preclerkship students in clinical skills at the bedside through a curricular program called the Colleges.21 Students gain hands-on, one-on-one clinical experience, with close observation and feedback from their faculty mentor and small group of peers.
The Colleges approach has been described.21 Briefly, weekly throughout students' second year, students within small groups are assigned one inpatient each from whom they take a history and physical examination; they then give a bedside oral case presentation and complete a write-up. The faculty mentor both guides the students and gives them some independence so that learning is active and contextual. After students' oral case presentations, the mentor and peers provide feedback, and the small group discusses the cases to advance students' clinical reasoning. Faculty also provide direct instruction and indirect teaching through role modeling in the patients' presence.
College faculty devote one-quarter of their professional time to teaching and mentoring students. Faculty are chosen through a competitive process open to all faculty in clinical specialties. Criteria include excellent teaching and clinical skills and interest in students. Faculty receive no special preparation for their roles, and there is considerable latitude in teaching approaches and styles in specific skills areas; written clinical skills benchmarks provide content standardization. The faculty meet regularly to discuss common teaching issues and approaches and receive periodic faculty development, often from peer faculty.
Most College faculty have worked with clerkship students and with residents. Before the start of the Colleges, preclerkship clinical skills teaching occurred in community preceptorships; consequently, few College faculty had worked with preclinical students. Therefore, the College curriculum and working with preclinical students' skill levels were new for most faculty. This curricular approach has been associated with improved student performance and greater comfort in clerkships.22,23
A longitudinal qualitative study was undertaken at the start of the Colleges program in 2003 to understand how clinician–teachers approach teaching. The longitudinal design was used to explore how faculty's skills and teaching approaches change over time. Initial comprehensive data coding of all transcripts was performed, with the intention of addressing more specific research questions related to the process and impact of teaching medical students. The study described in this paper addresses faculty's perceptions of the impact of their bedside teaching on their own clinical knowledge, skills, and attitudes.
One-on-one interviews were conducted with 31 College faculty members across five years, beginning at the end of the curriculum's first year. All College faculty during this time were invited to participate, and all who agreed to participate were selected. Interviews were conducted in summer 2003, fall 2004, and summer 2007, with the intention of conducting interviews approximately annually. Summer and fall interviews permitted reflection on the year just completed. In 2006, focus groups were held in place of interviews; results from those focus groups are not analyzed here because of the different format.
Instruments and data collection
Semistructured interview questions were developed by two educators and two clinical faculty and were modified each year to address emerging themes. Questions were piloted in early interviews. The initial question relevant to this study in first-year interviews was, “To what extent has working as a College faculty member influenced your own clinical skills?” The second interviews contained no questions about impact of teaching on faculty skills and clinical practices; however, those interviews were reviewed for comments about the impact of teaching on faculty clinical skills. The third interviews included no formal questions about impact of teaching on clinical skills, but many faculty were probed concerning changes in their clinical skills as a result of teaching at the bedside.
Five experienced interviewers conducted one-on-one interviews. Audiotaped 20- to 40-minute interviews were transcribed without identifiers. Interviews were scheduled for 30 minutes; differences in lengths of interview were based on interviewees' time constraints and verbal responses. Basic demographic data were collected.
The University of Washington institutional review board approved all instruments and procedures.
Three investigators reviewed all transcripts and coded passages using constant comparison and axial coding, techniques derived from grounded theory research.24 The emergent code relevant to this study from all three years was “mentor clinical skills.” This code related to the influence of teaching on physicians' own clinical skills.
Investigators isolated this code and reviewed relevant passages for themes. One investigator reviewed and coded all relevant passages; the other two investigators each reviewed and coded half of the passages. As themes emerged, discrepant data were isolated, discussed, and, if deemed significant, noted in the results. The three investigators then compared codes and developed a common code structure, isolating characteristic transcripts for each code. Codes were organized into larger clusters, or themes, and related to one another. Investigators also examined quotes for individual physicians over time and quantified positive, neutral, and negative comments concerning the impact of teaching on clinical skills. The longitudinal nature of the study provided a measure of validity through examination for recurrent themes. For further validation, after the study's conclusion, as part of an annual survey, College faculty were asked, in an open-ended survey question, what effect working as a College faculty had on their own clinical skills and work with their own patients, if any. Of 31 responses, 26 described positive change; 5 did not respond to the question. There were no negative responses. A conceptual model was developed to characterize the relationships between themes.
Participants and demographic characteristics
All 31 College faculty agreed to participate; not all faculty were able to complete all interviews because of availability and faculty turnover; therefore, interviews for some faculty are available for only one or two years. Twenty-nine faculty were interviewed two to three times, and two were interviewed once (total 82 interviews). Demographic characteristics of participants are shown in Table 1.
Six themes were associated with the influence of teaching on teachers' own skills and practices. Themes and subthemes are shown in List 1 and are examined in detail here.
Participants described three factors deterring their ability to maintain skills and gain new knowledge prior to teaching within the Colleges. One deterrent was the focus in one's own area of expertise or frequent usage of a narrow range of skills, whether in teaching or practice, so that other skills became foreign or were forgotten. One participant said,
I have gotten lazy over the years. We were talking about how you make the diagnosis. They say 90%, but more like 98% [comes] from history. A lot of the time I wasn't doing much physical exam in my own clinic.
Advanced-level teaching also constrained the breadth of skills used: “Third- and fourth-year students are more interested in my ... little narrow area. You assume they have some basic knowledge.”
A second deterrent was “automated practice”—the fast pace of practice, routines, and mechanical thought processes. Practice skills were lost through shortcuts:
[Before joining the Colleges] I came at patients very physician-centered. “I have so much time to see you and I'm going to start asking questions right away” versus “Tell me what's going on.”
Clinical reasoning also became automated:
... you're taking in information in a fast-moving clinic and going with some clinical judgment and you don't realize ... all the factors you're putting together to make an assessment and move on.
A third deterrent was reliance on tests, procedures, and consultants/specialists:
Maybe you heard a systolic murmur and [thought,] “Let's get an ultrasound,” instead of running through, “What are the provocative tests I could do that would heighten my likelihood of being right?”
Constructing knowledge and skills.
The second theme related to learning in preparation for, or resulting from, teaching. Two subthemes focused on learning mechanisms: self-directed learning and learning from students and peer faculty.
Self-directed learning often involved preparing for bedside teaching related to the organ-based curriculum (e.g., cardiovascular, gastroenterology) through reviewing books, notes, and other resources. Many faculty described refreshing, refining, and relearning knowledge they had not been responsible for since training: “I'm reviewing stuff I haven't reviewed in years. And it's making me a better clinician.”
Many physicians had forgotten or become rusty at knowledge and skills from earlier training or practice:
I found myself going back and reminding myself of physical diagnosis tests you don't use very frequently, having to relearn them.... Even going back and reminding yourself about the logical sequence of [deciding] when a murmur is clinically significant....
In the second subtheme, faculty described learning from students and peers. Medical students introduced recent or revised knowledge. One faculty said, “[Students] teach me stuff they've learned in classes, things that weren't known 20 years ago.”
Peer faculty played an educational role. Among diverse specialties, teachers learned from peers in areas they were teaching students at the bedside. Faculty refreshed knowledge and skills, learned new material, and sometimes learned that their clinical techniques were no longer the standard of care. A physician said,
To hear [a peer] talk about what is important in a [specialty] exam ... you find out [that] things you've been doing for years out of force of habit, he thinks are a waste of time.... [Laughs] Why have I been doing it then?
Deconstructing the clinical experience.
Working with students led faculty to examine their own clinical practice styles—reflecting on their thinking and practice. Four subthemes emerged: developing a slower practice time frame, increased awareness or consciousness of the clinical process, reducing care to a more basic level, and expanding and deepening one's practice.
In the first subtheme, working with students caused physicians to slow down: “I wanted to spend more time in clinical practice savoring that part of the exam.” Another physician realized that his fast pace negatively affected skills: “My clinical skills had gotten sloppy.... I'm always rushing around like an idiot. I've slowed down. I've listened to people more. I've felt people more carefully.”
The second subtheme related to increased awareness of the patient care process. Physicians thought more about what they were doing: “I'm more careful in my physical exam. It's more entertaining to know deliberately what you're doing and why.” As a result, physicians provided more thorough yet focused care:
... if I'm doing an HEENT [head, eyes, ears, nose, and throat] exam, it's a more complete HEENT exam. If it's a cardiac exam, it's a more complete cardiac exam than I did before.... [I]t's like rediscovering something; you're more attentive, you're more focused on it.
The third subtheme, breaking clinical care down to a more basic level, meant thinking consciously rather than relying primarily on tacit knowledge, pattern recognition, and other cognitive shortcuts. Several physicians used the word “dissect” to describe this process. For example, “We spend our time trying to dissect that interaction between the physician and the patient for the sake of our students. And it helps me dissect that in practice, as well.”
The fourth subtheme related to greater breadth and depth of knowledge, skills, and practice resulting from articulating a wider swath of practice and learning skills. This had several meanings. One was that in order to teach, one must know a subject well and in depth: “If you have to teach something, you have to know it cold, or you get halfway through and you're lost and get embarrassed.” Physicians teaching at the bedside with patients atypical for their practice found that their sphere of practice, whether primary care or specialty based, expanded; this expanded breadth of knowledge:
I see a lot of diseases and conditions [with students] that would never come across my path.... And then we can relate it to what we're learning in physical diagnosis and that makes it come alive. I'm a better clinician for it.
Practicing with a third eye.
This theme related to heightened self-awareness that translated from teaching to patient encounters and seeing oneself from the perspectives of others. Two subthemes emerged: awareness of being a role model and holding to that high standard at all times, and seeing patients through students' eyes.
In the first subtheme, physicians became conscious of the standard they set for students, holding to that standard in their practice: “... if I feel frustrated or irritated with a patient, sometimes my experience with students will make me say the same things to myself about being patient, being understanding.” Awareness of being a role model elevated physicians to continued consciousness of working at a high standard:
If you are expounding on the virtues of doing things a certain way, you gotta do it that way. I've become better at catching myself, if I'm ever slipping away from doing things in a good way.
In the second subtheme, physicians saw their own patients through students' eyes. This might involve wishing a student was present for a teaching opportunity or thinking about how to articulate, explain, or describe a patient to students:
I just examined somebody who had probably early Parkinson's syndrome. I'm thinking, how do you describe that, dissecting that clinically, how would I describe [it to] my students, how would I even tell them how I know what I know? Or how would I get them to know that?
The theme of perceived improvement of teachers' clinical skills focused on three primary areas: physical examination, interviewing/communication, and critical thinking.
Physical examination improvement, the most frequently mentioned clinical skills outcome, involved advancing exam skills and increased willingness to perform physical exams:
... some of the skills ... you just taught them so they're available to you in your own practice. Sometimes I'll do more things on the exam than I might have otherwise, so my physical exam skill set has increased.
The impact was more active involvement for a disease or condition that the physician might normally quickly refer to a specialist:
... it was no longer, just palpating and looking for the gross stuff and saying, “You need an orthopedics referral.” Now it was, “Before I send you to orthopedics, which I may anyway, I want to look for muscle atrophy and fasciculation.” I want to see if he had impingement. I want to see how much I can figure out myself.
Specific physical examination skills most frequently identified as improved were musculoskeletal, cardiac, and neurological; many physicians described general physical exam improvement.
Although many physicians felt they were already at a high level in interviewing, they frequently mentioned improved interviewing/communication: “[Teaching] changed me.... [W]hen I approach patients, I'm more consistent in starting out very open-ended. I'm more intentional rather than having it as a subconscious thing.”
The third area was critical thinking. A physician said:
There are times I'll reflect back and I made up my mind in the first 30 seconds, but then I'll think, “Oh, so what do I do about that?” Then I structure the rest of my time with the patient to get through stuff. It keeps me thinking, “What pieces do I need for this? What pieces do I pull out in my short times with patients?”
Another physician described change in self-articulation of reasoning: “... you're more stepwise in your reasoning, you're saying, ‘It's not this because of this. It's not this because of that.'”
Implementing the mindful practice.
Clinician–teachers perceived a strong impact of bedside work with preclerkship students on their overall patient care approach, describing a more conscious, mindful approach: “... it changes my attitude ... it's all tied up with mindfulness and being aware of my own feelings and why I'm feeling that way.” Others described this as greater awareness or acuity: “I find myself getting very, very clear stories on my patients. It's not that I didn't before; I'm more aware that that's what I'm doing.”
Subthemes were expression of greater self-confidence and comfort with challenges, using a more patient-centered focus, and greater practice enjoyment. Self-confidence manifested itself through greater comfort with difficult patients:
I get a list of patients that day. And invariably, you look down and go, “Oh, there's so-and-so. They're a challenge.” I used to dread seeing those names. Now I'm much more able to look at that as, “This'll be a challenge. This'll be cool. I'm gonna figure out a way to make a connection.”
Primary care physicians expressed greater confidence in specialty care involvement:
I was beginning to think more about my patients again, versus “I'll let the [hematology–oncology] doctor manage that.” I can step up a bit more because I've been thinking about these disease processes more while I'm talking to students.
Teachers focused more on their patients as individuals as a result of teaching, sometimes using direct lessons or approaches from their work with students: “... because of the things we've taught our students about patient-centered interviewing.... I like to think that I was doing that all along, but I had a lot of room for improvement.”
Many physicians expressed greater joy or pleasure in practice:
I'd lost some of the wonder of the privilege of being a physician. Working with students has given that to me, realizing this person is sharing intimate details with me; it's a wonderful thing and it's a privilege.
Trends in perceptions of skill improvement
Among 24 faculty who commented on the impact of teaching students on their own clinical skills in two to three interviews, 22 described positive impact in all interviews. One described no impact of improved clinical skills in the first interview but positive impact in a subsequent interview. Another described no impact in the first interview and was unsure in a subsequent interview. Of seven faculty who discussed impact on their clinical skills in one interview, six described positive impact on their clinical skills and one described increased self-awareness of personal skill deficits.
One faculty member qualified the positive impact with concern about excessive time dissecting the clinical thought process:
I found myself frustrated that I had spent so much time trying to dissect this pain complaint using a biomedical approach and not using my intuitive skills ... knowing this thing was not the thing that was really on this poor woman's brain.... These are important skills we're teaching, but students at some point are going to get to some advanced level beyond. But they can still go back and use these skills.
We compared themes and subthemes identified by primary care physicians and specialists. Both groups frequently described learning and relearning knowledge and skills, especially physical examination skills. Primary care physicians more frequently mentioned becoming more conscious of the process of care, focusing more on clinical reasoning, and becoming more self-confident. Specialists more frequently described becoming more patient-centered and improving interviewing and communication skills. There were no noticeable trends in comments by number of years teaching.
The conceptual model developed to portray the relationships between themes is shown in Figure 1. In this model, the practice environment, with associated deterrents to skills maintenance and new learning, is expanded by the learning and relearning associated with basic bedside teaching. This expansion results in deconstruction of the clinician's practice style to one characterized by greater breadth and depth of skills and practice, increased focus on process of care, slowing down, and awareness of basic knowledge and skills that scaffold the more sophisticated, automated practice-in-action. This transition to a different practice style has a dynamic tension with the existing practice environment, resulting in reconstruction of the teacher's clinical practice to heightened self-awareness of the process of providing care. At the broadest level of outcomes, the practice environment is transformed to one characterized by perception of improved clinical skills and greater mindfulness: self-confidence, focus on patients, and pleasure in practice.
This study describes perceived effects of sustained bedside teaching on clinician–teachers' clinical skills. These data suggest that working with students at the bedside may profoundly and positively impact teachers' clinical skills in two ways. First, through identifying their own clinical skills deficiencies while preparing for or during teaching, clinician–teachers became conscious of the need to rectify these. As described in the literature, this self-identification of deficiencies or areas of uncertainty concerning one's own knowledge and skills may have provided the motivation to move beyond a performance “plateau” and led to the commencement of reflective processes.14,15 Clinician–teachers who had come to rely primarily on history taking for diagnosis renewed their physical examination skills; increased use of physical examination in their own practices resulted in perceived positive impact on patient care.
Second, clinician–teachers developed a metacognitive approach to their skills and patient care—observing and reflecting on their skills and moving from unconscious to conscious, or tacit to explicit. Although tacit knowledge and pattern recognition are essential to clinical care, they may introduce habitual or automated behavior. However, clinical care cannot proceed at a constantly conscious level in which every observation and decision is subject to self-scrutiny. These data suggest the development of a state of practice comparable to the mindfulness described by Epstein and colleagues25,26: clinicians function with heightened self-awareness and self-observation, use a beginner's mind, and act with presence. This increases clinicians' practice enjoyment and patient involvement.
Clinician–teachers in this study described renewal and reinvigorated practice resulting from the process of bedside teaching, something central to their professional activities. Teaching led clinician–teachers to recognize areas of their “unconscious incompetence,” whether newly identified or resulting from disuse.27 Through being constantly engaged in bedside teaching, they held themselves accountable for continuously examining and renewing their skills. The result was perceived skill enhancement and, importantly, discovery or rediscovery of engagement in clinical practice through dissecting their practice, reflection, and reconstructing and experiencing their practice in a different, renewed manner.
This study suggests that teaching basic, foundational skills to medical students, compared with teaching at more advanced levels and in fast-paced clinical settings with competing demands, may have a strong impact on physicians' clinical skills. This setting causes clinicians to relearn clinical skills in combination with deconstructing their clinical experiences to a basic nature and then rebuilding them to a more conscious and thoughtful state. We believe this teaching must be sustained and is best performed at the bedside in the context of real patients. This provides a dynamic tension between the tendency of physicians to automate clinical practice and the impetus, through clinical teaching, to reexamine and become conscious of their own clinical practice.
This study has several limitations. It studies physicians' skills in relationship to teaching within one educational approach that uses tutors with dedicated time for bedside teaching with small groups of students longitudinally. Increasingly, the importance of sustained curricular teaching and solid foundational clinical skills has been recognized. This qualitative study, appropriate for theory building, does not prove the influence of teaching on clinical skills. Physicians' perceptions of impact on their own clinical skills are precisely that—perceptions. Further, this was a study in one institutional setting. The longitudinal nature of the study with recurrent themes over time mitigates this limitation.
To further explore and evaluate our findings, quantitative and qualitative comparisons are needed of the impact on clinicians' clinical skills of teaching in other settings and circumstances, including the more usual combination of teaching while providing clinical care, ambulatory teaching, and teaching advanced medical students and residents. Teaching foundational clinical skills and perhaps clinical skills teaching at other levels may be the best form of continuing education for clinicians, and this could encourage more physicians to become involved in, learn from, and appreciate the value of foundational bedside teaching.
The authors would like to acknowledge and thank Drs. Kelly Edwards, Sherilyn Smith, Lynne Robins, and Sharon Dobie, all at the University of Washington School of Medicine in Seattle, Washington, who participated in question development and planning.
This study was approved by the University of Washington human subjects board.
Data from this study were presented at the Western Group on Educational Affairs (Association of American Medical Colleges) meeting in Asilomar, California, March 2010, and at the Association of Medical Education in Europe meeting in Glasgow, Scotland, September 3–8, 2010.
1 Ramsey PG, Carline JD, Inui TS, et al. Changes over time in the knowledge base of practicing internists. JAMA. 1991;266:1103–1107.
2 Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260–273.
4 Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: A multicenter study. Arch Intern Med. 2006;166:610–616.
6 Collins J. Education techniques for lifelong learning: Lifelong learning in the 21st century and beyond. Radiographics. 2009;29:613–622.
7 Manning PR, DeBakey L. Continuing medical education: The paradigm is changing. J Contin Educ Health Prof. 2001;21:46–54.
9 Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867–874.
10 Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. Int J Technol Assess Health Care. 2005;21:380–385.
11 Marsick VJ, Watkins KE. Informal and Incidental Learning in the Workplace. London, UK: Rutledge Publishing; 1990.
12 Eraut M. Informal learning in the workplace. Studies Cont Educ. 2004;26:247–273.
13 Guest CB, Regehr G, Tiberius RG. The life long challenge of expertise. Med Educ. 2001;35:78–81.
14 Mamede S, Schmidt HG. The structure of reflective practice in medicine. Med Educ. 2004;38:1302–1308.
15 DA Kolb. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall; 1984.
18 Ramani S. Twelve tips for excellent physical examination teaching. Med Teach. 2008;30:851–856.
19 Hartley S, Macfarlane F, Gantley M, Murray E. Influence on general practitioners of teaching undergraduates: Qualitative study of London general practitioner teachers. BMJ. 1999;319:1168–1171.
20 Haffling AC, Håkansson A, Hagander B. Early patient contact in primary care: A new challenge. Med Educ. 2001;35:901–908.
23 Jackson MB, Keen M, Wenrich MD, Schaad DC, Robins L, Goldstein EA. Impact of a pre-clinical clinical skills curriculum on student performance in third-year clerkships. J Gen Intern Med. 2009;24:929–933.
24 Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, Calif: Sage; 1998.
25 Epstein RM. Mindful practice. JAMA. 1999;282:833–839.
26 Epstein RM, Siegel DJ, Silberman J. Self-monitoring in clinical practice: A challenge for medical educators. J Cont Educ Health Prof. 2008;28:5–13.
27 Swanwick T. Understanding Medical Education: Evidence, Theory and Practice. Hoboken, NJ: Wiley-Blackwell; 2010.