Reviewed by Kari Phang, MD and Patricia McBurney, MD
What was the study question?
What factors and dynamics are involved when residents/fellows attempt technical procedures on
real patients in the pediatric emergency department?
How was the study done?
A multi-phased qualitative study to explore how trainees learn procedures on real patients was
conducted at a Canadian tertiary pediatric emergency department. Staff physician preceptors,
residents/fellows, nurses and respiratory therapists were observed in the delivery and teaching of
technical skills over a 3-month period by two anthropologists trained in ethnography. After each
month and at the end of all 3 months, semi-structured interviews were conducted with participants,
learners and teachers. Four focus groups, two with teachers and two with residents/fellows, were
completed to determine if observations and interpretations resonated with others’ experiences.
What were the results?
In over 400 hours of observation 287 instances of technical skills were observed, of which 28%
were attempted by residents/fellows. Thematic analysis identified 14 factors, grouped into 3
categories, which influenced whether residents/fellows attempted technical skills on real patients.
Learner factors included initiative, perceived need for skill acquisition and competing priorities.
Teacher factors consisted of competing priorities, interest in teaching, perceived need for learners
to acquire skills, attributions about learners, assessments of competency, and trust. Environmental
factors were competition from other learners, judgement that the patient was appropriate, buy-in
from team members, consent from patient or caregivers, and physical environment constraints.
What are the implications?
Neither the presence of a learner in a clinical environment nor the trust of the supervisor were
sufficient to ensure a learner will attempt a technical skill. The authors characterize this
phenomenon as representing a pool of opportunities to perform technical skills on real patients
that shrinks to a much smaller pool of technical skill attempts. Preceptors, learners and education
leaders need to recognize and address the factors that support and inhibit the practice
opportunities required to achieve learner competency in technical skills. One promising lead is that
the preceptors’ interest in teaching was a powerful motivator for learners to attempt technical
Editor’s note: “See one, do one, teach one” needs to be supplemented with a lot of enthusiasm on the part of both
learners and teachers as well as promotion of confidence for both groups. That there are missed chances for
technical skill learning and practice in a busy emergency department is understandable but recognition of
inhibiting factors is a first step toward maximizing learning opportunities. (RR)