Overall, we saw two primary types of interactions during clinical supervision, one served to reach a conclusion on diagnosis and treatment, while the other prompted discovery. While the former category supported development of procedural knowledge, the latter category primarily consisted of interactions related to fostering conceptual understanding and the development of preparation for future learning. Both of these learning activities are understood to be core to adaptive expertise. Supervision to reach a conclusion is an integral and inherent part of every resident’s diagnostic process, and is important for patient satisfaction and safety (Jansen et al., 2020). Supervision to discover was more oriented toward learning, when there was time and opportunity to do so. Results indicated that this category of supervision echoed interactions previously described in the adaptive expert literature (Kua et al., 2021; Sockalingam et al., 2021; Mylopoulos et al., 2016), while adding new categories, such as shared discovery and orienting to new aspects of the case.
Is developing Adaptive Expertise a shared practice?
Results showed that learning opportunities were actively sought out by residents, but also by supervisors who had to facilitate the right time, content, and place for the supervision. Jansen et al. (2020) investigated residents’ help-seeking behaviours and argued that the act of requesting help was a delicately balanced act between not wanting to lose credibility and autonomy, but also providing high-quality care. They argued that a safe learning environment and an approachable supervisor was important for help-seeking. The present study demonstrated several co-regulated supervisions, and reported several instances where reviewing the patient was encouraged by the supervisor. This finding speaks to a shared responsibility for performing supervision. Teunissen et al. (2007) found that interpretation and construction of meaning by the resident, was fundamental for the expansion and refinement of residents' personal knowledge. Therefore, Teunissen et al. (2007) advise faculty to be aware of when and why they influence a specific phase of a resident's learning process. Similarly, Lockspeiser et al. (2016) found that residents benefit from interacting with senior staff setting and pursuing goals (Lockspeiser et al., 2016). Results from the present study indicate that the resident and the supervisor had a shared responsibility in creating and regulating learning situations during the clinical supervision. This finding echoes a recent study on informal workplace learning, arguing that providing and creating effectful learning situations in the workplace is a collaborative effort (Sehlbach et al., 2020).
Regulating learning is an important part of being an adaptive expert as these experts are able to monitor their level of knowledge and remedy the situation (Moulton et al., 2007; Mylopoulos and Woods, 2009; Mylopoulos and Woods, 2017). Within adaptive expertise, self-regulation refers to the cognitive ability to redirect one’s attention towards opportunities for closing knowledge gaps (Hatano, 1982; Hatano and Inagaki, 1986; Bereiter and Scardamalia, 1993). Self-regulation is referring to the action which epistemic distance elicits (Mylopoulos and Regehr, 2007), and has been framed as ‘looking up’ (Eva and Regehr, 2007) and ‘slowing down’ (Moulton et al., 2007) when needed. Results in the present study build on these framings by indicating a shared social responsibility in both the opportunity and ability to regulate learning. In this way, supervisors can engage residents in fostering conceptual understandings, by using the clinical supervision to prompt discovery and help residents to be aware of when they should direct their attention to their knowledge gaps.
Productive struggle through inquisitive supervision may feel like an examination
During clinical supervision, we observed residents experiencing struggle or failure in diagnosing the patient. Such failure and struggle has been highlighted in the medical education literature as a powerful educational tool that supports the development of conceptual knoweldge (Mylopoulos et al., 2016; Mylopoulos and Farhat, 2015; Steenhof et al., 2019). In a recent review, Klasen and Lingard, (2019) emphasize the social phenomena of allowing failure in health care and conclude that research should investigate why, when, and how supervisors can apply this technique (Klasen and Lingard, 2019). The reported findings in the present study demonstrate that productive struggle occurred through some degree of inquisition, which has been shown to support learning by encouraging learners to actively generate multiple possible, usually incorrect, solutions (Steenhof 2020). When asked, residents would respond that such inquisitions could feel like an examination and it is therefore important to discuss how supervisors balance power structures in more inquisitive approaches. Supervisors may know that the resident is working at the limit of their competence and may therefore see productive struggle or failure as a useful educational tool (Klasen et al., 2022). While Klasen et al. (2022) found that supervisors emphasize trainee confidence and personality as indicative of when to use productive failure as an educational tool, our study adds that a trusted relationship between the resident and the supervisor is an important factor. Otherwise, productive struggle often felt like an examination to the residents. Similarly, this stress the emotional aspect of learning from failure by highlighting that the emotional aspects may have a negative consequence on the learner (Klasen and Lingard, 2019; Fischer et al., 2006). Hence, findings in the present study emphasize an awareness about emotional aspects of productive struggle (Mylopoulos and Farhat, 2015; Steenhof et al., 2019).
While learning in the clinic is essential, the results in the present study also demonstrated that productive struggle could take place without harm to the patient. This was seen when residents reviewed patients to reach a conclusion, which was imperative for their ability to move on with their clinical work. Thus, in time sensitive situations (i.e., acute), striving to make supervision a learning opportunity with productive struggle might be inappropriate. The ethnographic data also demonstrated, that when residents sought supervision to discover, it was not necessarily noticeably more time consuming than more instructive approaches. Therefore, in non-time sensitive situations, supervision may be a good opportunity to engage in learning experiences that support the development of adaptive expertise. Here, the marginal additional time spend, may be a good investment in residents’ learning.
Implications for education
Results demonstrated that residents sought out supervision for two reasons; to confirm or to learn. However, as supervision is a shared practice, the decision to engage in learning activities may be a shared responsibility. This suggests that it might be relevant for supervisors to ask the resident of their intention for reviewing the patient, and being responsible for motivating supervision to discover when appropriate. Additionally, such a practice may mitigate the incongruity of the felt experience reported by some residents when they needed a clear answer to their questions, rather than being forced to engage in productive struggle. Being open to such learning activities is an important aspect of adaptive expertise (Crawford et al., 2005; Wineburg, 1998; Mylopoulos and Woods, 2009; Hatano, 1982; Hatano and Inagaki, 1986) and being coerced into learning practices can impede learning as the resident might refrain from engaging in future help-seeking behaviours (Jansen et al., 2020). As such, a match of expectations between the resident and the supervisor seems pivotal in order to engage in productive struggle.