Narrative Shifts Prompt the Development of Adaptive Expertise in Pediatric Subspecialty Residents

In an era of increasing complexity in healthcare, it is necessary for physicians to be flexible and adaptive in their use of knowledge and experience to solve new, unexpected and multifaceted problems in clinical practice. This complex problem solving is known to be an essential skill for adaptive experts and is the standard of excellence in training future health care professionals. Despite its importance for medical training, little is known about how adaptive expertise develops in medical trainees. Specifically, we do not know how residents accomplish the tasks of learning to integrate knowledge using integrated competencies as seen in adaptive experts, yet this understanding is key when considering how best to design curricula and instructional methods to help residents develop these skills. Therefore, the purpose of this study was to explore how residents develop these integrative skills in Pediatric medicine. A constructivist grounded theory study was conducted, using participant observation and semi-structured interviews as the data sources and purposeful sampling of residents from the Department of Pediatrics at the University of Toronto, to explore how residents develop integrative skills of adaptive expertise through workplace learning. We conducted 34 observations of ten residents, resulting in 102 hours of observation over the course of 12 months. Data collection and analysis occurred iteratively and themes were identified through constant comparative analysis by a team of researchers. Our results demonstrated that residents have acquired a number of routine efficiencies for communicating with patients and families during clinical consultations. While these well-developed approaches are effective in most clinical situations, residents navigated difficult or challenging conversations by enabling families to express their own narratives. They integrate this information with their medical knowledge and their own perspectives and values. At times, residents recognized that a ‘narrative shift’ was needed to effectively navigate the conversation. This shift was used purposefully to inform the creation of new communication strategies, resulting in an opportunity for new learning. Critically, this learning was modulated by the resident’s effectivities and the constraints of the clinical setting. Narrative shifts are adjustments in the clinician’s understanding of a patient’s narrative that impacts on how clinical care is provided. They are one representation of how integrated knowledge and competencies seen in adaptive experts are enacted in daily clinical work. In this study, narrative shifts prompted learning in residents. They triggered residents to explore and experiment with new ways of interacting with patients and families which further developed their conceptual understanding of how their knowledge is situated within the context. These narrative shifts also prompted them to seek multiple perspectives for approaching these conversations with families. The workplace learning environment provides opportunities that prepare residents for future learning through active experimentation, deeper conceptual learning and multiple perspectives. As we transition to competency based education, we must ensure that these key aspects of training that promote adaptive expertise development are not lost.