Medical Grand Rounds featuring Dr. Jessica Trier
Sophia Linton, PhD Candidate (TMED) and Graduate Student TA
Signaling the start of the Fall term, it is a tradition for the Queen's Department of Medicine Medical Grand Rounds to begin with Education Rounds. This year we have welcomed Dr. Jessica Trier, a physician in the Department of Physical Medicine and Rehabilitation, to speak to us about effective coaching relationships and the clinical practice learning environment. After the Rounds, the graduate students in Translational Medicine (TMED) joined Dr. Trier to discuss her research and experience in Competency-Based Medical Education (CBME) and her career.
The clinical learning environment (CLE) can be defined as the overlapping space between the work environment and the educational context. This overlap is complex, so much so that Nordquist and colleagues approach the CLE from six avenues: architectural, digital, diversity and inclusion, education, psychological, and sociocultural (1). When the CLE is suboptimal, it has been associated with adverse patient care and learning outcomes, contributing to higher levels of stress, burnout, depersonalization, and emotional exhaustion in medical trainees and their teachers (2,3). Clinical coaching has emerged as an educational strategy to improve resident learning. The coaching model is different from the traditional concept of pedagogy because it aims to strengthen task execution through coaching feedback and does away with the presumption that, after a certain point, the student no longer needs instruction (4). Dr. Trier referenced the Coaching by Design (CBD) model developed by the Royal College (5). In this model, coaching feedback focuses on specific, actionable suggestions for improvement and occurs in the moment and over time.
Dr. Trier continued to introduce several coaching frameworks but focused on one called the R2C2. The R2C2 model describes four phases for assessment discussions with medical learners: (1) develop Rapport and relationship, (2) explore the trainee's Reactions to the feedback, (3) assist in understanding Content of feedback, and (4) Coach to identify performance or knowledge gaps, then set goals and plans (6–8). Dr. Trier's research focuses on applying the R2C2 for in-the-moment feedback where coaching conversations occur immediately after a specific clinical experience (9). In-the-moment feedback is especially beneficial for CBME settings where learners are expected to meet milestones or complete entrustable professional activities (EPA). Dr. Trier performed a framework-type analysis with colleagues to successfully create and test a new tri-fold for effective R2C2 in-the-moment feedback. This resource is available online for all clinical educators (9).
A safe bidirectional relationship between coach and coachee is key for the R2C2 framework to be productive. In Rounds, Dr. Trier asked the audience to think about a time in their residency where they felt safe enough to take a risk and why. The answer has to do with psychological safety or the belief that you won't be punished or shamed for speaking up with ideas, questions, concerns, or mistakes. Dr. Trier explained that psychological safety is associated with improved p atient care outcomes because team members have improved communication and are more likely to report errors. She segued to the complex ideological concept of allowing failure for educational purposes in the CLE, saying optimal knowledge occurs when both psychological safety and performance accountability are high. Many audience members resonated with this question, contributing personal stories and anecdotes of their experience with interpersonal risk-taking. We continued this conversation post-Rounds, asking how EPAs and CBME could impact psychological safety in the CLE and learned the jury is still out; interpersonal risk-taking behaviors and their effect on residents are unclear (10).
A common thread of our time with Dr. Trier was the importance of practicing a growth mindset where people believe their basic abilities, like intelligence or skills, can be developed through perseverance and hard work. This mindset contrasts with a fixed mindset, where people believe their basic qualities are fixed traits. Dr. Trier stressed that coaches and coachees must have a growth mindset for coaching relationships to be effective and safe. When asked about the benefits of being a clinical coach with a growth mindset, Dr. Trier referenced her practice as a physiatrist. She explained how her desire to grow enables her to learn from the residents and her multidisciplinary team, ultimately improving patient care.
As TMED students, this presentation allowed us to appreciate the complexity of medical education and encouraged us to reflect on our mindsets as biomedical researchers. On behalf of the TMED students, I want to thank Dr. Trier for her time and reminding us of our roles as translators of medical discovery driven by patients and their diseases.
1. Nordquist J, Hall J, Caverzagie K, Snell L, Chan M-K, Thoma B, et al. The clinical learning environment. https://doi.org/101080/0142159X20191566601 [Internet]. 2019 Apr 1 [cited 2021 Sep 13];41(4):366–72. Available from: https://www.tandfonline.com/doi/abs/10.1080/0142159X.2019.1566601
2. Irby DM. Proceedings of a conference chaired by Improving Environments for Learning in the Health Professions [Internet]. 2018. Available from: www.macyfoundation.org
3. C K, A W, C B, P F, N F, M H, et al. A national stakeholder consensus study of challenges and priorities for clinical learning environments in postgraduate medical education. BMC Med Educ [Internet]. 2017 Nov 22 [cited 2021 Sep 13];17(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29166902/
4. Gawande A. The Coach in the Operating Room | The New Yorker [Internet]. Annals of Medicine, The New Yorker. 2011 [cited 2021 Sep 13]. Available from: https://www.newyorker.com/magazine/2011/10/03/personal-best
5. Coaching and CBD :: The Royal College of Physicians and Surgeons of Canada [Internet]. [cited 2021 Sep 13]. Available from: https://www.royalcollege.ca/rcsite/cbd/implementation/wbas/coaching-and…
6. Sargeant J, Mann K, Manos S, Epstein I, Warren A, Shearer C, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ [Internet]. 2017 Apr 1 [cited 2021 Sep 13];9(2):165. Available from: /pmc/articles/PMC5398131/
7. J S, JM L, K M, H A, A W, M Z, et al. The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use? Acad Med [Internet]. 2018 Jul 1 [cited 2021 Sep 13];93(7):1055–63. Available from: https://pubmed.ncbi.nlm.nih.gov/29342008/
8. Bannister SL, Wu TF, Keegan DA. The Clinical COACH: How to Enable Your Learners to Own Their Learning. Pediatrics [Internet]. 2018 Nov 1 [cited 2021 Sep 13];142(5). Available from: https://pediatrics.aappublications.org/content/142/5/e20182601
9. Lockyer J, Armson H, Könings KD, Lee-Krueger RCW, Ordons AR des, Ramani S, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ [Internet]. 2020 Feb 1 [cited 2021 Sep 13];12(1):27. Available from: /pmc/articles/PMC7012514/
10. JM K, LA L. Allowing failure for educational purposes in postgraduate clinical training: A narrative review. Med Teach [Internet]. 2019 Nov 2 [cited 2021 Sep 13];41(11):1263–9. Available from: https://pubmed.ncbi.nlm.nih.gov/31280625/