Scoping review
Scoping reviews are an ideal tool to determine the coverage of the body of evidence on a topic [13], [14], [15]. These reviews can help to identify the types of evidence in a field, examine how research in a field is conducted, identify the key characteristics of a concept, inform a systematic review, and analyze knowledge gaps [14]. For this study, we utilized a scoping review to identify behavioral attributes that correlate with effective service provision and which are not indicators of clinical acumen or academic performance. The behavioral attributes from the scoping review served as discussion prompts in the group exercise described later in this section.
We undertook steps in the scoping review in line with guidance provided in a seminal paper by Arksey and Malley [13]. We identified the research objective of the scoping review as aiming to describe behavioral competencies required for medical practice. We then performed a search on Google and PubMed for relevant studies, including peer-reviewed articles and grey literature, published in English, between 1st January 2007 and 30th June 2019, regardless of methodology or country of focus. The search algorithm included the following terms: values, behavior, competence, medical practitioner, doctor, medical professional, health practitioner, health professional, auxiliary, non-cognitive, non-clinical, non-academic, selection criteria, selection process, situational judgment test, and review.
Following the initial search, the title and abstract of each publication were reviewed to verify compliance with the inclusion criteria described above, and the bibliographies of identified studies were reviewed for other publications that may be eligible for inclusion. The full text of the final set of included studies were reviewed by two independent researchers to extract the behavioral competencies required for medical practice and definitions of the identified behavioral competencies (if any). Drawing on these definitions, duplications were removed, and a list of non-overlapping behavioral competencies was derived.
Nominal group technique (NGT) exercise
The NGT is a group consensus-building method that aggregates the opinions of individuals that have experienced a phenomenon using a structured format [16], [17], [18]. Through anonymous voting, it promotes equal opportunity for participants to contribute, reduces the influence of dominant speakers in group interactions, and ensures that individual voices do not skew the debate. For this study, we used NGTs to elucidate the consensus of medical students and professionals on the behavioral competencies required for physicians to provide effective care.
The NGT exercises were conducted in May – June 2019 in the College of Medicine, University of Nigeria, given the availability of physicians involved in clinical practice and training, including medical students and doctors in the affiliated teaching hospital, and whose input might inform more formal guidelines on intake into medical school and residency training. At the face-to-face recruitment, participants were informed that the aim of the study was to determine important behavioral competencies required for medical practice in Nigeria.
The study team purposively selected twenty medical students in the penultimate and final year of clinical training, and who had thus been exposed to rotations in internal medicine, surgery, pediatrics, obstetrics and gynecology, and community medicine, of whom seventeen (eleven males and six females) consented to participate. The study team also purposively selected twenty medical residents, equally distributed among the main clinical specialties: internal medicine, surgery, pediatrics, obstetrics and gynecology, and community medicine. Eleven residents (three males and eight females) consented to participate.
We held one NGT with medical students in May 2019 and another with medical residents in June 2019. Discussions were held in a quiet, secluded room situated in the University teaching hospital. All discussions were conducted in English Language and audio-recorded with the consent of the participants. Hand-written notes describing the group interactions were taken by a member of the research team.
Each NGT started with a review of the objective of the discussion and the process of conducting NGTs. The starting list for the discussion was derived from the results of the scoping review on the global evidence on behavioral competencies required for medical practice, that were grouped based on their relevance for interactions with clients or colleagues by the study team and participants. During the NGT exercise with resident doctors, this starting list had been modified to reflect the list of competencies generated from the first NGT exercise with the medical students.
The study question of identifying behavioral traits that are essential to effective practice among medical professionals was restated. In round robin fashion, that is with one response per person per round, everyone in the group was given the opportunity to add to the starting list, with three rounds in total. The responses were recorded on a flip chart without criticism. Repetitions and overlaps between responses were noted, clarifying questions were asked when needed, and participants attempted to provide definitions for each competency.
Based on the updated list, participants were asked to anonymously select and then rank five most relevant competencies for interactions with clients and with colleagues. Each list of five competencies was then ranked in order of importance for effective practice, with “5” indicating the most important competency and “1” indicating the least important competency. The aggregate score for each competency was generated by summing the numerical scores. Results from the voting and ranking were discussed. Participants were then asked to re-rank their original top five ideas for each interaction. The aggregate score for each behavioral competency and changes from the first round of voting were calculated. An overview of the NGT process is provided in Figure 1 below.
Drawing on the updated list and definitions, we triangulated our findings across the scoping review and NGTs. We compared the final list of competencies defined by medical students with medical doctors, and the respective rankings of each competency for doctor-client and doctor-colleague interactions using an arbitrarily-selected decision rule (aggregate ranking of greater than equal to 10) that reflected relative consensus on the importance of the competency. We then identified parallels between behavioral competencies common across both groups and the results of the scoping review of the global literature.
Three members of the research team are physicians, who have experience providing primary and specialist care. The other member of the research team has a graduate degree in health promotion and communication. One of the members of the research team with significant prior experience conducting NGT exercise provided training to the other team members involved in data collection. The guide for the NGT was also discussed with experts from other disciplines, to ensure that the guide and probes were free of pre-conceived opinions of the research team on the subject matter. The study findings have been reported in line with the consolidated criteria for reporting qualitative research (COREQ) [19].