Perceptions of scheduled vs. unscheduled directly observed visits in an internal medicine residency outpatient clinic

INTRODUCTION: Learners may subconsciously change their behavior once they know they are being observed, and this Hawthorne effect should be considered when designing assessments of learner behavior. While there is a growing body of literature to suggest direct observation is the ideal standard for formative assessment, the best method to directly observe learners is unknown. We explored scheduled and unscheduled methods of direct observation among internal medicine residents in the outpatient continuity clinic to advance the understanding of both observation methods. METHODS: We conducted a thematic analysis of faculty and internal medicine residents in an outpatient clinic setting. A semi-structured interview guide for focus group sessions was created. Focus groups were used to explore the internal medicine resident and core teaching faculty perceptions of the scheduled and unscheduled direct observation methods in the outpatient clinc. An experienced qualitative research interviewer external to the internal medicine residency was moderating the sessions. Eight peer focus groups were held. Abstraction of themes from focus group transcripts identified resident and faculty perceptions of the different observation methods. RESULTS: Focus groups had 14 resident participants and 14 faculty participants. Unscheduled observations were felt to be more authentic than scheduled observations since residents perceived their behavior to be unmodified. Unscheduled observations allowed for increased numbers of observations per resident, which permitted more frequent formative assessments. Residents and faculty preferred remote video observation compared to in-room observation. Participants found direct observation a useful learning tool for high-yield, specific feedback. CONCLUSIONS: Unscheduled remote direct observation captures authentic clinical encounters while minimizing learner behavior modification. An unscheduled observation approach results in more frequent formative assessment and therefore in more instances of valuable feedback compared to scheduled observations. These findings can help guide the best practice approaches to direct clinical observation in order to enhance residents learning and experience.