title: Teaching during consultation: factors affecting the resident-fellow teaching interaction.
abstract: OBJECTIVE
  The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident-fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning.
  
  
  METHODS
  We conducted four focus groups of IM residents (n = 18) and IM subspecialty fellows (n = 16) at two academic medical centres in the USA during February and March 2013. Participants represented trainees in all 3 years of residency training and seven IM subspecialties. Four investigators analysed the transcripts using a structured qualitative framework approach, which was informed by literature on consultation and the theoretical framework of activity theory.
  
  
  RESULTS
  We identified two domains of barriers and facilitating factors: personal and systems-based. Sub-themes in the personal domain included fellows' perceived resistance to consultations, residents' willingness to engage in teaching interactions, and perceptions and expectations. Sub-themes in the systems-based domain included the process of requesting the consult, the quality of the consult request, primary team structure, familiarity between residents and fellows, workload, work experience, culture of subspecialty divisions, and fellows' teaching skills. These barriers differentially affected the two stages of the consult identified in the focus groups (initial interaction and follow-up interaction).
  
  
  CONCLUSIONS
  Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.
authors.affiliation: Division of Rheumatology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Eli M
authors.initials: EM
authors.lastname: Miloslavsky
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Jakob I
authors.initials: JI
authors.lastname: McSparron
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Jeremy B
authors.initials: JB
authors.lastname: Richards
authors.affiliation: Clinician Educator Service, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Alberto
authors.initials: A
authors.lastname: Puig
authors.affiliation: Shapiro Institute for Education and Research, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Amy M
authors.initials: AM
authors.lastname: Sullivan
mesh_terms: D001291:Attitude of Health Personnel; D004503:Education, Medical, Graduate; D017144:Focus Groups; D006801:Humans; D007388:Internal Medicine; D007396:Internship and Residency; D010820:Physicians / Q000523:psychology; D024382:Professional Role; D036301:Qualitative Research; D012017:Referral and Consultation; D013663:Teaching / Q000379:methods*; D014481:United States