Learner Perspectives on the Learner Handover Process

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On this episode of the Academic Medicine Podcast, Tammy Shaw, MD, MMed, and Research in Medical Education (RIME) Committee member Arianne Teherani, PhD, join host Toni Gallo to discuss new research into learner perspectives on the learner handover process. They discuss the role of trust in this process, the potential for bias, the purpose of handovers vs. how they’re perceived by learners, and recommendations for making handovers safer and more effective.

This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.

This episode is the first in this year’s 3-part series of discussions with RIME authors about their medical education research and its implications for the field. Check back next week for the next episode in this series.

A transcript is below.

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Transcript

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Toni Gallo

Before we get into today’s episode, I’m really excited to announce that you can now claim CME credit for listening to this podcast. Academic Medicine is offering this service free of charge. There’s no cost to you. All you have to do is visit AcademicMedicineBlog.org/cme, listen to the 8 episodes listed, then follow the instructions to claim your credit. This is an annual activity so you can claim these credits once between now and next July. And annually, we’ll be updating the list of included episodes and additional credits will be available. You can find more information at AcademicMedicineBlog.org/cme or you can email AcademicMedicine@aamc.org with questions. As always, thanks so much for listening, and here’s today’s episode.

Toni Gallo

Welcome to the Academic Medicine Podcast. I’m Toni Gallo. Every year Academic Medicine publishes the proceedings of the annual Research in Medical Education or RIME sessions that take place at the AAMC’s Learn Serve Lead meeting. This year, the RIME papers, including the one we’ll be talking about today, will be presented throughout the Learn Serve Lead meeting, which is taking place in Seattle, Washington, in November. The RIME papers are available now to read for free on AcademicMedicine.org. As in previous years, I’ll be talking to some of the RIME authors on this podcast about their medical education research and its implications for the field.

For the first of this year’s conversations, I’m joined by Dr. Tammy Shaw, who authored the paper, “Having a Bad Day is Not an Option: Learner Perspectives on Learner Handover.” Also, joining us today is a member of the RIME Committee, Dr. Arianne Teherani.

So Tammy and her coauthors interviewed medical students and residents about their perspectives on the learner handover process and its impact on their education, their current and future careers and their wellbeing. And we’ll be talking about the role of trust in learner handovers, the purpose of handovers versus how they’re perceived by learners, the potential for bias in this process and recommendations for making handovers safer and more effective.

So I want to start with introductions. Tammy, would you like to go first?

Tammy Shaw

Sure. I’m Tammy Shaw. I’m an assistant professor at the University of Ottawa in the Division of General Internal Medicine. And I did my master’s of medical education through the University of Dundee. And my education hat is associate program director for our core internal medicine trainees.

Toni Gallo

Wonderful! Welcome. Arianne?

Arianne Teherani

Hi, I’m Arianne. And I am a professor of medicine, also in the Division of General Internal Medicine at the University of California, San Francisco.

Toni Gallo

Thank you both for being here today. So Tammy, I want to give you a chance just to tell us briefly about the study that you did and maybe share some key findings for listeners.

Tammy Shaw

We studied learner handover. So learner handover, learner education handover, is basically the sharing of information between supervisors involved in a learner’s education. And it can occur in different processes, so between rotations, sort of informally in the hallway between staff. And it’s been something that’s been talked about for many years but come back into the literature related to CBME and transitions between undergraduate and postgraduate education. So the idea of giving the next staff or the next program information about the learner and their strengths and their deficits and what they can improve on to prepare them for the next steps of their training.

Our main goal was there wasn’t much in the medical education literature about what learners thought about this in the real world. So that’s what we sort of sought out to find. And what we had found was they didn’t really know really what was going on in the background. They had a sense of the information being shared but weren’t sure why it was being used when it was being shared and the purpose. And that actually caused a lot of fear and stress about the implications on, not just their learning and how they can improve, but also future careers down the line.

Toni Gallo

Something that came up in a number of the themes in your paper was the idea of trust or really mistrust that the learners had in the system. And so I wonder if you could just talk a little bit more about that piece and kind of how trust came up in your findings?

Tammy Shaw

So, trust certainly is a fundamental aspect of a lot of relationships, including the student-teacher relationship as well as the student and the system in which they’re learning. And what came out was, if there was not a lot of trust in terms of how information was being shared and what the purpose for the information, the students would fear the worst and things would catastrophize beyond that. So they weren’t really sure what the purpose of sharing their weaknesses, say future on. It sounds like those who did trust the system and those who felt that learner handover was okay, which were rare, it sounded like they had a good relationship with their teachers or they chose more of a longitudinal system where they could grow and learn from one specific person and see the outcome from that. And a lot of it had to do with mutual goals and openness to listening to other people’s mistakes and being aware that they can improve. But when people don’t know when the information is being used, then that’s a little bit more difficult for them to trust that it wasn’t going to be used in a negative light.

Toni Gallo

I wonder, Arianne, if you can jump in here. I know you think about assessment and equity and assessment and maybe how does that play in here with the idea of trust and handovers and how learners are seeing the information that’s being shared about them?

Arianne Teherani

I first have to say it was pretty eye-opening, the role that trust played. It played a critical role in the study. And I realized that Tammy and her team did decide to look at the data through the trust angle. And I think what we saw in the sense of sort of mistrust of the system structure, the handover, learners only having a vague idea of the informal practices around handover that are occurring and how it could potentially affect their perception of their performance, their career prospects, among other high stake consequences. And the fact that there was also some discussion of anxiety. So I thought this was very eye-opening and a very interesting lens in order to be able to look at this data from.

And what was also interesting was the fact that learners, whether they were high or low performing, did allude to these findings. And that was also something that we hadn’t often thought about in the assessment sphere. You would always worry that it’s the low performers that would worry more, but this seemed to come up among groups of performers regardless. And just the idea that sometimes not even knowing that the handover was happening was pretty critical.

And I think at the same time, it was also kind of interesting that there was this sense of trust, that learners recognized that the handover’s potential utility could be pretty significant in their learning and in patient safety. That I think really underscored the fact that trust in the system, if executed appropriately and if clear and transparent, can really make this idea of utility to learning, patient safety, manifest and flourish.

And I think building on that and really answering Toni’s question about equity, I have to say I thought about every theme in this paper from the lens of equity because that is an area that I work in. And I did think to myself, for example, some of the work that we have seen around how learners feel, the learning environment and assessment practices can be inequitable, particularly if they come from groups that are minoritized or marginalized historically within the context that they are in, can actually have a much more profound deep impact on their performance. So some of that sense of mistrust, that worry about always having to perform or always having to be on and showing the best side of you would be much more complex and magnified for learners who are just trying to learn. I mean after all, the whole point of medical education is to educate. We tend to reward those who start strong and stay strong, but if that’s what we’re going to do, that minimizes the importance of education, which is supposed to make you learn.

So anyway, I did think about every theme in this paper from the angle of equity and what it would’ve meant for different learners from different backgrounds and identities.

Toni Gallo

So, you’ve both alluded a little bit to this idea of handovers are really meant to aid in education, aid in growth, but the way that students kind of perceived them was,” I’m so afraid of failing, I don’t want to ever admit that I don’t know because I don’t want that to get passed on.” And so there’s this discrepancy between learner development and this perception they have of what’s really happening in the handover process. And so I wonder if you both can talk a little bit about that. The purpose versus how students are really seeing this and how those 2 things seem to kind of be at odds.

Tammy Shaw

Yeah, we actually found that really interesting as well. As you’ve mentioned, one of the main purposes of learner education, learner handover, is to be learner-centered and focused on development and professional developmental of both skills and professional identity. But what the learners did point out was there are probably multiple purposes of learner handover and they already knew that from the get-go, even if they weren’t quite aware when it was happening or what was going on. And there are other papers to suggest this from the faculty perspective, that we don’t just use learner handover for educational purposes from the faculty. Sometimes it’s for survival mode as well. So you’re spending a weekend with a resident that you’ve never met and you talk to each other about what to expect, how much supervision does this resident need? So that’s survival and that’s also patient safety and deciding how much you can entrust this new resident that you’ve never met before.

And when that comes into play, the residents started thinking about other means or other ways that the information that was being shared was being used. The challenge of learner handover and just residency training altogether is there’s dual purposes. You want to make an impression because these are ultimately the people that are going to be hiring you in the long run, but you’re also trying to be a student and trying to learn. Because they’re different purposes and because you have a dual role of feeling like you’re always on an interview, you always feel that you can’t make a mistake and that sort of challenges that psychological safety that we all need to be able to learn and develop and cope with mistakes that often happen in medicine that happen to all of us no matter how strong we are.

Arianne Teherani

I think a slightly different perspective that I also took on the data, because I thought about, like I said, a lot of it through the lens of what it would mean for learners who came from different backgrounds. In some of our earlier work, we had done some qualitative work on beginning to really understand what made for an assessment system in clinical learning that was equitable. And through this process of this particular narrative study, we learned that–and I won’t get into the details of what made for an equitable system–but what we did learn was that even in order for us to think about equity, there are certain best practices. There are certain, what we call sound assessment practices that have to be in place first in order to be able to really think about what’s needed and then in order to then build on that for equity.

And I think some of the things that came up in this study were very much reflective of those sound assessment practices, even in the context of the handover. So for example, some of the characteristics of a sound assessment system really are this ability to have a lot of observation and feedback along the way to help one grow. Clearly you need that for the handover as well, right? You have to be able to know, and I think Tammy, you identified very nicely in your paper how that’s completely lacking. Also, just being able to have people that you work with continuously over time who can see you grow. So those kinds of things are all inherent to sound assessment practices that I do think translate over into this context of discussion on handover growth and progress for individual learners.

Toni Gallo

One of the other concerns I think that learners had, Tammy, in your paper, was the fear that bias was getting passed along down the line from one evaluator or supervisor to the next. And I wonder if you could talk a little bit about how that came up in your work. And then maybe, Arianne, you can talk about that idea as well.

Tammy Shaw

So, bias was one of the reasons why faculty were also hesitant to implement learner handover in the medical education structure. Often they would talk about learner handover to help those who needed a little bit more assistance throughout their residency training. But a lot of the schools that, although they suggested it, were a little bit hesitant to implement it. And one of the reasons is because of bias. The residents and the medical students in the paper, they weren’t wrong when they were worried about bias. When you look into the literature, there were some studies in medical education, one was the paper that my thesis was based on, that if you got negative information prior to seeing a resident perform or a learner perform, that would actually affect the assessment to being more negative compared to if you got positive feedback prior to seeing that resident perform.

Medical education doesn’t have a lot of these studies. There was another one that it actually affected–in Montreal, I think–that actually affected the number of comments in the area that they were worried about. But other social sciences, like business, they did study this quite a bit and they did consistently show changes in perception and assessment related to the information that was provided prior to this. And that’s sort of what we continue to try to study in medical education. The learners are scared and there is validity to why they’re scared. We do need to do more studies about whether a supervisor saw the resident more often or more frequently, if they saw them during an assessment during the workplace where there’s more distractions versus being able to do it in a clinic setting without distractions, if those real world factors actually change that. But that’s sort of where that study on bias came from and why we were looking for that theme, whether the residents and the learners were kind of aware of that, were also fearful of that.

Arianne Teherani

I thought a lot about your findings toward the end of a paper around transparency and the safe learning environment and really how important those were as a direction which assessment should go. Everything that you just described about just concerns in general about the handover and the carryover of information and what we know about the inequitability of the clinical grading process, how I spoke earlier to the fact that it favors learners who start strong and stay strong. Those worries and those stakes would play out very strongly for learners. And regardless of background, but I think a lot for learners who may actually not have as strong a foundation as others.

And I think that feeling and stress of constantly being evaluated can be pretty significant. And there is some work around stereotype threat in medical education and how that also can impact and further exacerbate some of the worries around performance and well-being and fatigue and anxiety and all those things among learners. So I do think that exploring some of the themes that you’ve identified in the study even more and what are the interventions and the ways in which we can think about transparency and safe environment that go alongside with the handovers will be very critical to the next phase of work in this area.

Toni Gallo

In your discussion, Tammy, you extrapolate some suggestions for improving the handover process so that it’s safer, more effective for learners. Maybe you can share some of those with us, please.

Tammy Shaw

One of the major findings was part of the reason the learners were fearful is they didn’t know what was being shared, when it was being shared, and how the information was being used. So I think one of the things that can help them is if we made the entire process very transparent, like Arianne was saying earlier in the interview. Having them involved in the process, letting them read what’s being written about them, showing them that it’s not all bad, that we’re also focused on their strengths and how to build upon that and how to make good residents great, how to make deficits a little bit better and really truly make it learner-centered like it’s meant to be and like CBME was designed to be.

There was a study recently on learners and they tried this in a small number of learners and those who actually agreed to have their learner handover and be a part of the process sent to their next residency program, looked at learner handover in a more positive light than those who did not agree to do it because they had an idea and were more optimistic about the entire process and that it’s actually for them. So I think transparency is one of the bigger factors.

We always talk about, we need a cultural change. So medical education as we know, we are likely doing better because we’re more aware about things like wellness and studying more about equity and diversity and things that can stress the residents out and trying to be more forgiving on ourselves with increasing work on burnout. But I think that’s going to take some time and little things matter and the little things would be making things a little bit more open, talking about staff’s own uncertainties, our own deficits, how we work through them, doing little things that make the environment a little bit safer to have weaker areas. And then knowing that people who are doing great can also sort of falter a little bit and that everybody is allowed to have a bad day essentially.

Arianne Teherani

And that they will. And that that’s a normal part of practice and growing even when you are a full-blown physician out in the workforce. So I think those are very legitimate points.

And I really also just want to build a little bit on this idea of the creation of learning opportunities that arise based on the handover. So really the transparency around that but also creating dedicated learning opportunities to help learners fill the gaps in their knowledge and skills. Having the ability to fail and learn and grow without worrying about the high-stakes consequences. And we do want learning settings that foster that kind of growth thinking. But when that system isn’t there, it just interferes with everything from well-being to success. And I think that the system that has the safety and the growth mindset in place can really help contribute to that.

And a couple of years ago, Lee Seligman had done this work on when institutions, they transitioned from tiered grading to pass-fail grading in the clerkships with additional feedback on how it really affected medical students’ learning experiences. And what he found was that students’ descriptions of the change in their approach to assessment and engagement in the clerkships, their well-being and their recognition of the learning context completely changed. They talked about having things like a sense of agency over their learning. They talked about mastery rather than performance. They actually sought out ways to seek feedback. And their well-being was definitely characterized as much more low stress. And so I do think that there is some initial evidence that really supports some of the things, Tammy, that you just said and that you found in that work, particularly on transparency and opportunities for growth in the safe learning environment.

Toni Gallo

A big area of work is the transition from undergraduate medical education to graduate or postgraduate medical education and what that looks like and who’s sharing what information and how it’s being used. And so Tammy, I wonder if any of the findings or themes that came up in this study you think might have relevance to that conversation. And if there’s any suggestions that you might have for that transition.

Tammy Shaw

I agree that is one of the reasons why learner handover came back into the forefront of the literature, this transition between undergrad and postgraduate, and getting ready for the next learners that are coming through. I think they’ve already, both the American and Canadian organizations that are developing some of these guidelines, they’ve already considered some of the findings. And to add to that, they did talk about learner-centered and having the learner involved in that process, so building up learning plans so that they know exactly what’s being transferred, ensuring that there are structures available. So, it’s all good and well that we say this person is good here and needs a little bit of work in this area, but having that infrastructure in place to support that learner through their development.

One of the biggest things I think would also be having everything a little bit more standardized so that we’re not just choosing specific residents or future residents that need this type of learning plan because we can all improve in some ways and making sure that everybody goes through it and they don’t feel like they’re being picked on. I think those are some ways that we can improve on the work and continue doing this sort of to help the residents grow from undergraduate to postgraduate.

Toni Gallo

We’re about at the end of our time. I want to give you each a chance if you have final thoughts. Tammy, anything else you want to share with listeners or maybe where this work is going next, if there are other questions that this sparked for you and your team and where you’re hoping to look next.

Tammy Shaw

I think the biggest thing that I wanted to point out is learners are quite fearful. I think that’s sort of what came out. And it’s causing more emotional stress beyond what we hope that they feel. We always hope that our learners are comfortable telling us when they’re struggling a little bit or when they make a mistake because that’s sort of how we learn. I’ve learned best from the things that I should have done rather than the things that I’ve done well through my training. And I’ve been lucky to have some supervisors who understood that and was able to guide me a little bit more. But some of these learners, they go from, it’s a mistake for this one session to I’m a horrible doctor. And I think we have to do better and make sure that we stop that process and we really make them understand a mistake is a mistake, it’s going to happen, and it’s how we cope with it.

I think what this brought up is the importance of, like we were talking about the psychological safety and learning environment in the past, and I think our work should continue on more studies around how to make that happen. How much of this is an issue, and through either simulation in the workplace, if you see a resident more than once, does that help decrease the bias that you might see from the learner handover? If there’s more disruptions to your day, does that increase or decrease? Adding a diversity component to it might actually help as well. How much of these factors are playing a role in what we’re seeing? So there’s a lot of work to be done.

Arianne Teherani

If we want to stand behind our belief that we should have a competency-based medical education system, learner handover is pretty critical to that and to letting students grow and learn. We do need to have a transparent, honest, and trustworthy system in place. And I do congratulate this group on the critical work that really helps establish a solid set of directions and next steps. A larger study I think that establishes these findings with more learners, like you said, from diverse backgrounds. And really thinking about some of the principles, the interventions, the learner handover interventions that help establish trust with the learners, help them grow, are definitely very important next steps.

Toni Gallo

Well, I want to thank you both for joining the podcast today. And I want to encourage our listeners to look for Tammy’s paper, which is available on the Academic Medicine website right now. You can go read that for free. So thanks very much.

Tammy Shaw

Thank you for having me.

Arianne Teherani

Thank you.

Toni Gallo

Remember to visit AcademicMedicine.org to find the article we discussed today as well as the other RIME articles. Be sure to check back next week for the next episode in this year’s RIME series. We’ll be talking about a qualitative study that explored faculty and student perceptions of unauthorized collaborations.

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