title: 'Sometimes the work just needs to be done': socio-cultural influences on direct observation in medical training.
abstract: BACKGROUND
  Direct observation promises to strengthen both coaching and assessment, and calls for its increased use in medical training abound. Despite its apparent potential, the uptake of direct observation in medical training remains surprisingly limited outside the formal assessment setting. The limited uptake of observation raises questions about cultural barriers to its use. In this study, we explore the influence of professional culture on the use of direct observation within medical training.
  
  
  METHODS
  Using a constructivist grounded theory approach, we interviewed 22 residents or fellows (10 male, 12 female) about their experiences of being observed during training. Participants represented a range of specialties and training levels. Data collection and analysis were conducted iteratively. Themes were identified using constant comparative analysis.
  
  
  RESULTS
  Observation was used selectively; specialties tended to observe the clinical acts that they valued most. Despite these differences, we found two cultural values that consistently challenged the ready implementation of direct observation across specialties: (i) autonomy in learning and (ii) efficiency in health care provision. Furthermore, we found that direct observation was a primarily learner-driven activity, which left learners caught in the middle, wanting observation but also wanting to appear independent and efficient.
  
  
  CONCLUSIONS
  The cultural values of autonomy in learning and practice and efficiency in health care provision challenge the integration of direct observation into clinical training. Medical learners are often expected to ask for observation, but such requests are socially and culturally fraught, and likely to constrain the wider uptake of direct observation.
authors.affiliation: Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. chris.watling@schulich.uwo.ca.
authors.forename: Christopher
authors.initials: C
authors.lastname: Watling
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Kori A
authors.initials: KA
authors.lastname: LaDonna
authors.affiliation: Department of Medicine and Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Lorelei
authors.initials: L
authors.lastname: Lingard
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Stephane
authors.initials: S
authors.lastname: Voyer
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Rose
authors.initials: R
authors.lastname: Hatala
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence / Q000592:standards*; D004503:Education, Medical, Graduate; D017598:Efficiency, Organizational; D005260:Female; D066296:Grounded Theory; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D007858:Learning; D008297:Male; D019370:Observation; D017009:Professional Autonomy; D036301:Qualitative Research