“learning the lingo”: a grounded theory study of telephone

“Learning the lingo”: A grounded theory study of telephone talk inclinical education

Eppich, W. J., Dornan, T., Rethans, J-J., & Teunissen, P. W. (2019). “Learning the lingo”: A grounded theorystudy of telephone talk in clinical education. Academic Medicine.https://doi.org/10.1097/ACM.0000000000002713

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Download date:22. Apr. 2022

https://doi.org/10.1097/ACM.0000000000002713

https://pure.qub.ac.uk/en/publications/aee213ae-7a56-45bc-a403-b45b7e392900

1

“Learning the lingo”: A grounded theory study of telephone talk in clinical education 2

3

Walter J. Eppich, MD, PhD 4

Tim Dornan, MD, PhD 5

Jan‐Joost Rethans, MD, PhD 6

Pim W. Teunissen, MD, PhD 7

8

Dr. Eppich is associate professor of pediatrics‐emergency medicine and medical education, 9

Northwestern University Feinberg School of Medicine, Chicago, USA 10

11

Dr. Dornan is professor of medical education, Queens University, Belfast, UK, and emeritus 12

professor at Maastricht University, the Netherlands 13

14

Dr. Rethans is professor of human simulation and director of medical education programs 15

Maastricht University, the Netherlands 16

17

Dr. Teunissen is professor of medical education at Maastricht University, the Netherlands 18

19

20

21

Corresponding author: 22

Walter Eppich, MD, PhD 23

Ann & Robert H. Lurie Children’s Hospital of Chicago 24

Division of Emergency Medicine 25

225 E. Chicago Ave Box 62 26

Chicago, IL 60611 27

Telephone: 312‐227‐6080 28

Fax: 312‐227‐9475 29

Email: [email protected] 30

31

Each author made substantial contributions to conception and study design. WJE collected all 32

data. Each author contributed to analysis and interpretation of data as well as drafting and 33

reviewing the article critically for important intellectual content. Each author takes take public 34

responsibility for the entire work. 35

36

37

38

39

ABSTRACT 40

Purpose: Although the workplace learning literature has focused on ‘doing’, clinical practice 41

involves ‘talking’ not only with patients but also about patients with other health professionals. 42

Work‐related telephone conversations among clinicians are common, but their contribution to 43

doctors’ learning remains underexplored. Using a socio‐cultural perspective, the authors 44

examined how telephone talk influences physicians’ clinical education. 45

Methods: Using constructivist grounded theory methodology, the authors conducted 17 semi‐46

structured interviews with doctors from a variety of specialties and training levels from two 47

American academic medical centers between 2015‐2017. They collected and analyzed data 48

iteratively using constant comparison to identify themes and explore their relationships. 49

Theoretical sampling in later stages occurred until sufficiency was achieved. 50

Results: Residents and fellows reported speaking on the phone regularly to facilitate patient 51

care and needing to learn how to tailor their talk based on goal(s) of the conversation and their 52

specific conversation partners. Three common conversation situations highlighted the interplay 53

between patient care context and conversation and created productive conversational tensions 54

that influenced learning positively, namely experiencing and dealing with (a) power 55

differentials, (b) pushback, and (c) uncertainty. 56

Conclusions: Telephone talk contributes to postgraduate clinical education. Physicians‐in‐57

training learn both ‘how to talk’ and ‘learn through talk’ on the telephone mediated by 58

productive conversational tensions that motivate them to modify their behavior to minimize 59

future tensions. An evolution of ‘how to talk’ enables physicians‐in‐training to advocate for 60

their patients and promote patient care. Preparing residents to deal with pushback could 61

support their learning from this ubiquitous workplace activity. 62

63

INTRODUCTION 64

While research on clinical workplace learning often focuses on how students and 65

residents learn from ‘doing’,1-4 much of clinical practice involves ‘talking’ not just with patients 66

but about patients with other health professionals. As in other occupations,5,6 ‘talk’ 67

encompasses verbal and nonverbal content and its accompanying social implications and 68

comprises a significant component of clinical work. Moreover, according to both psychological 69

and sociocultural theorists, talk mediates learning,7,8 making learning inseparable from patient 70

care. Although researchers have examined how medical students learn oral presentation 71

skills,9-12 we have much to learn about how talk shapes clinical education. 72

Each day physicians‐in‐training speak with many conversation partners for a wide 73

variety of reasons, e.g. to coordinate patient care across distributed teams or to seek/give 74

advice about patient management. The distributed nature of modern healthcare spreads 75

cognition across multiple agents in space and time, highlighting how language impacts macro‐76

cognitive processes like sense‐making and decision‐making.13 A clearer understanding of 77

workplace talk would help us to delineate its specific contribution to clinical education. 78

Work‐related telephone conversations represent a useful setting to study learning from 79

healthcare workplace talk. Limited research has outlined strategies for telephone interactions 80

between doctors seeking advice from subspecialist physicians.14-16 These studies do not explore 81

the intrinsic learning potential of telephone conversations. Further, they only touch on the 82

social nature of telephone interactions and frame them primarily as transactions of information 83

exchange between conversation partners. We need to study the influence of social aspects 84

such as hierarchy and power on learning from telephone conversations. 85

Different perspectives illuminate different aspects of talk. We chose a sociocultural lens 86

that emphasizes both social and individual dimensions of talk to human development and 87

learning.17,18 Sociocultural speaking, talk mediates human thought, forms social structures, and 88

gives people agency; all are integral to learning.18,19 Thus, as junior physicians‐in‐training 89

progress in their clinical training, talk plays a vital role in their evolution from peripheral to full 90

participants in their community of practice,19 a perspective reflected in works exploring 91

socialization in medicine.20-23 A socio‐cultural perspective helps us examine how telephone talk 92

influences this developmental trajectory. We recognize that multiple approaches exist for 93

studying talk in social contexts. Conversation analysis (CA) is often used to study talk and social 94

interactions and involves recording and analysis of actual conversations to “identify stable 95

practices and underlying normative organizations of interactions”.24 However, since we were 96

interested in motivations and perceptions behind telephone conversations, we chose 97

constructivist grounded theory (CGT),25,26 a qualitative methodology suited to explore complex 98

social phenomena unexplained by pre‐existing theory. 99

Better understanding of residents’ and fellows’ telephone talk would yield valuable 100

insights to promote practice improvements and clinical education. Thus, we used residents’ and 101

fellows’ accounts of their work‐related telephone conversations as a model to study healthcare 102

talk to answer the research question: How do telephone conversations contribute to 103

postgraduate medical trainees’ workplace learning? 104

105

METHODS 106

Using CGT, we sought to derive a conceptual framework explaining the role of work‐107

related telephone conversations in resident and fellow clinical education. CGT encourages 108

researchers to include their own backgrounds and perspectives.25 All four authors are 109

physicians with significant experience in medical education research; WJE and PWT remain 110

active clinicians. Additionally, PWT and TD have extensive backgrounds in qualitative research. 111

The study took place at an accredited medical school in Chicago in the United States. 112

Using targeted recruitment emails based on training program directors’ suggestions, we invited 113

residents and fellows across postgraduate years from various specialties from multiple 114

residency and fellowship programs between 2015 and 2017. Several residents, including one at 115

another large academic medical center in the United States, were invited via email at the 116

suggestion of participants who had already been enrolled. Participants received no 117

compensation or incentive. We obtained informed consent from each participant. The ethics 118

committee at Ann & Robert H. Lurie Children’s Hospital of Chicago approved this study. 119

One investigator (WJE) conducted all individual semi‐structured interviews with an 120

initially purposive sampling of residents and fellows from December 2015 to February 2017. All 121

interviews focused on patient care‐related telephone conversations between doctors and other 122

health professionals. Open ended questions invited participants to describe their experiences 123

speaking on the telephone with other clinicians to advance patient care. See Appendix for 124

interview guide and follow up questions. Following CGT methodology, we collected and 125

analyzed data iteratively using constant comparison.25,26 Interviews were audio‐taped, 126

transcribed, reviewed for accuracy, and de‐identified. 127

The analysis proceeded in three phases, first with line‐by‐line coding and using constant 128

comparative analysis of initial interviews to create focused codes. Two co‐authors (WJE, PWT) 129

coded a sub‐set of interviews to ensure consistent coding; disagreements were resolved 130

through discussion. Further analytic meetings in pairs (WJE and TD or WJE and PWT) served to 131

elevate and combine key concepts into identify major themes. The entire team met to examine 132

the relationships among major themes to theorize how work‐related telephone conversations 133

contributed to learning. As per CGT methodology, in latter stages of iterative data collection 134

and analysis we recruited additional participants whose specialty and training level allowed us 135

to refine aspects of our evolving conceptual model that remained unclear. Data collection 136

ended when our analysis achieved theoretical sufficiency.25-27 We used MAXQDA (Berlin, 137

Germany) to facilitate data management, interpretation, coding, and memoing. 138

139

140

141

RESULTS 142

We interviewed seventeen physicians‐in‐training (11 male, 6 female) from post‐143

graduate year 1 through 8 across a variety of specialties from three different academic 144

hospitals participated. See Table 1 for an overview of participant characteristics. Anonymous 145

participant codes identify representative quotations (e.g. P004). All participants reported 146

speaking regularly on the phone with a wide variety of conversation partners depending on 147

their role, practice domain, and urgency of clinical situations. Participants reported needing to 148

learn how to tailor their talk efficiently and effectively based on goal(s) of the conversation and 149

their specific conversation partners. 150

For participants, the dynamic interaction between clinical situations requiring telephone 151

conversations and their respective conversation partners contributed to their learning 152

potential. Young doctors learned how to talk in terms of ‘what to say’ related to informational 153

and social content as well as the rhetoric of ‘how to say it’. Our participants highlighted that 154

both ‘what to say’ and ‘how to say it’ signified culturally sanctioned and expected ways of 155

talking that were influenced by and reflective of their developmental trajectory from junior to 156

more senior physician. This evolution in ‘how to talk’ directly enabled them to enact safe, 157

effective, and progressively efficient team‐based patient care. 158

Our participants encountered three common conversational situations repeatedly 159

during work‐related telephone talk that generated tensions. These productive conversational 160

tensions seemed to influence learning positively since they prompted doctors‐in‐training to 161

adapt their talk over time in order to manage these tensions. Thus, these tensions contributed 162

both to how participants ‘learned how to talk’ and how they ‘learned through talk’ (see Figure 1 163

for a visual overview of major themes and subthemes). The three situations that exemplify 164

productive conversational tensions included experiencing and dealing with: 165

Power differentials 166

Pushback 167

Uncertainty while also striving to embody trustworthiness 168

169

Experiencing and dealing with power differentials 170

Many participants reported experiencing power differentials among conversation 171

partners that seemed to both help and at times hinder learning. For example, a number of 172

participants reported experiencing emotional reactions when calling attending physicians. They 173

used words like ‘intimidating’ and ‘feeling nervous’ that highlighted the role of ‘hierarchy’ in 174

healthcare and needing to learn how to manage nervousness and threats to self‐confidence. 175

176

When I’m calling an attending…there’s some voice in the back of my head asking me 177

whether or not that call should be made or if that’s going to…be perceived 178

negatively…or also just my own hang‐ups about not wanted to feel weak. (P004) 179

180

Perceived asymmetry across hierarchical boundaries could influence learning positively. 181

When presenting a patient to senior supervising physicians (attendings), participants wanted to 182

be “as good as [they] can be” (P001) and embody trustworthiness by organizing their thoughts 183

ahead of time. Participants often had an acute information need in the form of input from an 184

attending physician or a consultant in order to advance patient care, at times under time 185

pressure. In perceiving situational asymmetry in terms of role and information need, junior 186

participants often felt pressure to prepare ahead of time in order to deliver a concise oral 187

presentation of relevant information to the best of their current abilities. 188

189

You don’t want to call your attending up in the middle of the night…and then clearly not 190

[have] thought about what’s going on with a case. It’s just disrespectful to totally throw 191

your hands up and wake them up without [giving it] any thought....And there’s just a 192

self‐respect aspect of it‐‐I don’t want them to think I’m an idiot. (P009) 193

194

Participants also mentioned repeatedly how a lack of collegiality or “politesse” (P015) 195

especially from someone up the hierarchy or from other medical specialties triggered strong 196

emotional reactions and negatively impacted the conversations and thereby learning. These 197

situations reflected unproductive tensions such that when conversations became unpleasant, 198

residents just wanted to end the conversation, often to the detriment of their learning. 199

200

I always want to know ‘why’ this decision is being made. Knowing ‘the why’ helps me... 201

respond [next time]. With negative conversations, you can sometimes lose ‘the why’ 202

and not really care anymore…because the situation becomes frustrating. (P008) 203

204

Given these negative experiences, participants reported seeking to lessen perceived 205

power differentials, which enabled “sort[ing] through our thought processes at the same 206

time” (P008). Participants at a similar training level often taught each other. For example, one 207

pediatric fellow reported discussing the rationale or ‘the why’ for certain treatment decisions in 208

particularly challenging cases with another subspecialty fellow, noting that “I come away from 209

the conversations feeling like I now know something that I didn’t before” (P009). Similarly, the 210

importance of establishing collegial working relationships‐‐not only with peers but also across 211

boundaries of hierarchy and medical specialty‐‐came up repeatedly. 212

213

[Over time] you can be…more informal and still convey the relevant points, but joke 214

around and have a little bit more fun…It’s professional relationship but there’s also a 215

personal component to it…you have shared respect for each other. (P006) 216

217

218

Experiencing and dealing with pushback 219

Most participants mentioned the experience of having to deal with “pushback” (P009) from 220

conversation partners. ‘Pushback’ denotes situations when the doctor had a clear need or ‘ask’, 221

but the conversation partner ‘pushed back’ and questioned the request or suggested course(s) 222

of action. Some frequently mentioned examples of pushback included: 223

When seeking subspecialty advice, the consultant—usually another physician‐in‐224

training—expressed that formal consultation was unnecessary or inappropriate 225

altogether 226

When admitting a patient to the hospital, the admitting service (resident or fellow) 227

responded that admission was either unwarranted or inappropriate for their service 228

When calling for urgent assistance, differing perceptions of relative urgency and 229

priorities created tension 230

231

Participants highlighted the need to learn to deal with and even anticipate pushback 232

depending on urgency and clinical requirements. Many advocated keeping the goal in mind “to 233

get what you want” (P005) and working towards a mutually amenable solution by “continuing 234

to be a rational, reasonable human being who may have a difference of opinion, but can talk 235

through that with the other person” (P011). Depending on the circumstance, however, 236

telephone pushback led to frustration “because I didn’t necessarily get what I wanted [and] the 237

team didn’t necessarily get what they wanted” (P002). With increasing clinical experience, 238

however, participants realized they didn’t always need to get ‘what they wanted’. 239

240

In medicine most of the time when there’s a difference of opinion, it’s kind of 241

subjective…[so if] it’s not going to hurt the patient, it’s fine. You pick and choose those 242

battles...you’re storing up your ability to push your opinion harder when it really 243

matters. (P011) 244

245

Participants reported multiple approaches to deal with pushback. These strategies 246

included taking the conversation partner’s perspective ahead of time, anticipating and pre‐247

empting pushback, and keeping the goal of the conversation in mind. When pushback arose, 248

participants recommended asking “what are you concerned about?” … then “reason[ing] 249

through those explanations” (P008) to solicit the conversation partner’s perspective. Dealing 250

with pushback in situations in which ‘it really matters’ required “all the tricks in your convincing 251

playbook”; these tricks included being “really nice”, then “firm”, then a “little less nice….a little 252

more direct” then “direct almost to the point of being rude about it” before “going up the 253

chain” (P005). Several participants commented on the strategic use of “the higher‐up's 254

authority…[and] just say[ing] ‘the attending wants this, so please do this’” (P016). Especially for 255

junior residents, ‘the higher up in medicine is always a trump card’ (P012). Finally, many 256

participants emphasized that telephone communication had limits. When “you’re not seeing 257

eye‐to‐eye…you need to stand with the nurse [or] resident and look at the patient together so 258

that you can make sure that you’re really on the same page” (P010). Additionally, residents also 259

reported learning how to address concerns directly: 260

261

One strategy I learned as a resident when a nurse is much more concerned about a 262

problem than I am, you can say, “What concerns you most about this problem?” That 263

gives the [other person] the opportunity to express their concern; and it also gives you 264

the opportunity to say, “Okay. Well, this is why I’m not concerned about this particular 265

problem.” It gives you a chance to explain yourself. 266

267

Many participants raised the issue of ‘rambling’ as a precursor to getting pushback since 268

it magnified uncertainty and frustrated listeners. Rambling described a disorganized and 269

unfocused mode of presenting information often without a recognizable purpose for the 270

listener that made pushback more likely, especially for juniors. While pushback was most often 271

viewed as something to overcome, unpleasant tensions associated with pushback also seemed 272

to serve as implicit feedback. One resident reported that when conversation partners pushed 273

back on the phone they could “get a little abrupt with questions and give [you] a hard time. 274

[But when] you call them and they don't say anything and you're like ‘that's what they want’ ‐‐ 275

that's better” (P016). Getting progressively less pushback over time, thus, indicated a moment 276

in which young doctors were aware of their clinical progress. 277

278

Experiencing and expressing uncertainty while embodying trustworthiness 279

Many participants expressed having feelings of uncertainty. While uncertainty will 280

always exist, participants worried about coming across as unsure of themselves and feared 281

being viewed as “hedging” (P017), being “wish‐washy” (P014), or “smelling like an intern” 282

(P006). For example, 283

284

You get a lot of pages from nurses about little things…and sometimes you’re not sure. 285

I often feel like I have to check with my senior…Sometimes, I do know the answer, and 286

that’s great…But sometimes I do have to say, “I don’t know. I’m going to call you back” 287

(P002) 288

289

To this end, participants reported learning to be direct in expressing uncertainty while 290

instilling confidence through “confident, adult, medical terms ‐ not in scared, I’m still a student, 291

terms” (P011). Participants commented on their efforts to embody trustworthiness, engender a 292

sense of confidence in their telephone communications and “make a good impression” (P013) 293

particularly with unfamiliar conversation partners. Participants outlined important strategies 294

for making a good impression and establishing trustworthiness, some of which we have already 295

highlighted. First, many participants recommended taking the conversation partners’ 296

perspective and information needs into account in order to achieve the goal of the exchange. 297

With experience, participants learned to consider their audience and 298

299

…put myself in their shoes and think about what they want to know…and not really give 300

anything else that they don’t want to know about, cater your information towards their 301

level and their specialty…(P008) and …speak the language…these specialties want to 302

hear. (P002) 303

304

Additional concrete strategies included: having a clear goal in mind, framing the 305

conversation at the outset, and synthesizing information rather than merely being the 306

“gatherer and reporter” of it (P010). For many participants, the first substantive sentence 307

grabbed attention and anchored the rest of the conversation “because people won't listen 308

unless they know what they're listening for” (P016). Participants also stressed the importance 309

of “learning the lingo” (P008) in order to “paint a picture” (P003), through use of “buzzwords” 310

(P007) that conveyed key information and urgency succinctly and persuasively. Crisp, organized 311

presentations over the phone were highly valued, especially when seeking advice from 312

consultants or more senior physicians. Many participants identified the trial‐and‐error nature of 313

gaining these rhetorical skills, which they viewed as a developmental process inextricably linked 314

to caring for patients. As one upper level fellow noted, being more succinct is “partly because 315

you’re using fewer words, and partly that you sound more confident because you are more 316

confident” (P011). 317

In addition, many participants reported that effective and efficient communication over 318

the phone engendered trust. Importantly, a sense of being viewed as trustworthy contributed 319

to an evolving sense of autonomy. In seeking attending input about a deteriorating patient, one 320

participant recounted 321

322

[The attending was] asking me what’s my assessment…and trusting what I’m telling her 323

over the phone… [And her] asking, “What have you done so far and what do you want 324

to do?” … That represents telecommunication autonomy, ‘Yes, I’m going to trust what 325

you’re giving me, right now, over the phone’ (P007). 326

327

DISCUSSION 328

We explored telephone talk in postgraduate medical education and found that work‐329

related telephone talk represents a significant workplace activity for physicians‐in‐training. 330

Given their highly social nature, a socio‐cultural lens allowed us to examine telephone talk as 331

physicians‐in‐training progressed along a developmental trajectory from more peripheral to 332

more central members of their community.18 In doctors’ communities of practice, learning how 333

to talk and manage interactions skillfully conveys a sense of clinical and social 334

competence,9,10,20,28 which makes clear, concise, and persuasive communication highly 335

desirable. However, not only did young doctors learn how to talk, our findings highlight that 336

telephone talk also mediated learning as well. 337

Tensions often arise during healthcare telephone talk. Reasons include urgent clinical 338

situations requiring use of telephone communication, time‐sensitive information needs, 339

frequent boundary crossing between specialties and professions, varying abilities to 340

communicate effectively, and efficiently and a lack of visual nonverbal social cues. Although 341

prior work has framed ‘communicative tension’ primarily as unproductive,29,30 our findings 342

show that ‘productive conversational tensions’ contribute to physician workplace learning, 343

even though doctors‐in‐training often find these tensions unpleasant. These productive 344

tensions arise primarily from power differentials, dealing with pushback, and walking the line 345

between expressing uncertainty while at the same time embodying trustworthiness. In line with 346

work about ‘tensions’ in operating room teams29 and on the telephone,30 we purposefully use 347

the term ‘productive tensions’ rather than conflict. Especially in healthcare, the term ‘conflict’ 348

frequently has negative connotation, although recent calls encourage the healthcare field to 349

take a more nuanced view of conflict in healthcare teams.31,32 Our study’s main findings 350

contribute to this more differentiated view. 351

‘Productive conversational tensions’ during telephone talk contribute to learning in 352

several ways. First, these tensions keep trainees ‘on their toes’ when speaking to people above 353

them in the healthcare hierarchy. Second, by experiencing pushback, doctors‐in‐training must 354

articulate their thinking clearly, justify their point of view when differences of opinion and time 355

pressure exist, accept alternate perspectives when appropriate, and choose their battles 356

depending on patient care needs. Third, productive conversational tensions serve as valuable 357

‘performance relevant information’,33 by highlighting knowledge deficits or an inability to 358

assess a situation or communicate clearly and convincingly about it. For example, other authors 359

have addressed how physicians learn to express uncertainty, mostly through linguistic devices 360

or rituals34 or using sanctioned language and particular grammatical structures, e.g. modal 361

auxiliaries such as ‘can, could, may’ or adverbs like ‘perhaps’ or ‘possibly’.10 362

Of course, not all conversational tensions are productive. Genuinely disruptive behavior 363

falls well outside of the range of productive and even threatens patient safety. Such behavior 364

includes yelling, abusive language, or a condescending tone35 that some of our participants also 365

reported. Further, evidence indicates that rudeness has negative impacts on performance for 366

individuals36 and teams.37 In addition, our data showed how unproductive tensions impair 367

learning since residents lose the desire to learn the ‘why’ behind recommendations from 368

seniors and consultants since they understandably seek to end unpleasant conversations. 369

Although we show that tensions can be productive, clinical supervisors might infer that we 370

should create ‘productive’ tension intentionally, which our data do not suggest. Indeed, we 371

should minimize unproductive tensions or frank conflict. 372

Our work builds on these findings by emphasizing how the overall arc of a telephone 373

conversation (how it is framed at the outset, its organization, its inclusion of only relevant 374

information) enables doctors to express uncertainty with a ‘manner of certitude’.10 Further, 375

our data and analysis suggest that physicians also learn to manage issues of power and 376

hierarchy through several conversational phenomena: (a) topic control38 through “framing” 377

that directs the topic under discussion, (b) conversational repairs to address issues of speaking, 378

hearing and understanding,24 and (c) back‐channeling,39,40 i.e. cues listeners provide to support 379

and guide the conversation. These findings justify attention to social learning occurring in this 380

medium. 381

Our findings suggest that physicians‐in‐training learn through their participation41 in 382

work‐related telephone calls and adapt their behavior in order to: (a) conform to the workplace 383

culture and communication practices and (b) minimize tensions in future encounters. Indeed, 384

by conforming to the way things are done, junior doctors participate in reproducing the 385

community of practice18 and adopt established or reified communication patterns,4 with both 386

desirable and undesirable consequences. Reified communication structures19 support shared 387

understanding but may limit the agency which allows doctors to respond to unique and 388

uncertain situations4,42 Talk seems to mediate the dynamic balance between structure and 389

agency while promoting both resilience and learning in work systems that demand adaptation 390

to the unexpected in both talk and action.43,44 Interestingly, no participants in our sample 391

reported use of pre‐learned conversational structures such as SBAR (situation‐background‐392

assessment‐recommendation).45 393

Our study has important implications for medical education. We replicate prior work 394

that stresses the important role of effective oral presentation skills.9 For example, especially 395

when junior residents ‘ramble’ on the phone, their unfocused presentation magnifies 396

perceptions of their uncertainty and prompts others to others question their competence. 397

Also, the extent to which physicians‐in‐training experience pushback adds to stress levels and 398

perceived workload, which raises additional key questions. Should we help junior residents 399

develop their communication skills and ‘don a cloak of competence’46,47 and ‘disguise their 400

uncertainty’10 as the community of practice seems to require? Or should we seek to create a 401

learning environment where uncertainty is normalized? Either way, we could achieve this aim 402

by enhancing junior doctors’ ability to articulate uncertainty in a way that promotes 403

trustworthiness, to persuade and convince, to deal with pushback, and to mitigate rather than 404

stoke unnecessary tensions. 405

Several decisions related to our data collection and analysis potentially impact our 406

results. First, we included only physicians‐in‐training in our sample which excludes other 407

perspectives, such as nurses. This choice perhaps explains why the notion of ‘tensions’ as a 408

contributor to learning featured prominently in our analysis. Alternately, by including only 409

physicians‐in‐training across a breadth of specialties and training levels, we could explore key 410

situations from various vantage points through the lens of early career doctors. 411

Future research on healthcare telephone talk should prioritize several key areas. First, a 412

needs assessment for telephone talk would guide robust curricula for physicians‐in‐training and 413

their supervisors. Second, we should explore how power differentials impact telephone 414

conversations and what characterizes pushback on the telephone. Third, we need to examine 415

how text messaging technology shapes telephone communications. Fourth, further study 416

should will delineate the potential negative impact of “framing” on potential anchoring bias,48 417

something we did not explore. Finally, additional methodological approaches to this 418

phenomenon would contribute additional insights to our understanding of this educationally 419

rich workplace activity. 420

421

CONCLUSIONS 422

Telephone talk contributes to postgraduate clinical education since physicians 423

simultaneously learn how to talk and learn through talk. Learning through telephone talk 424

appears at least in part to be mediated through productive conversational tensions that can 425

motivate physicians‐in‐training to modify their behavior in order to minimize future tensions 426

and provide efficient patient care. Education on ‘how to talk’ on the telephone could prepare 427

residents to deal with the pushback they experience and support their learning from this 428

ubiquitous workplace activity. 429

430

Acknowledgements and Disclosures 431

Acknowledgments: The first author (WJE) wishes to thank Jan Schmutz, PhD, for his support 432

during the writing process. 433

Funding/Support: The first author would like to thank the Grainger Fund for supporting this 434

research. 435

Other disclosures: none 436

Ethical approval: The institutional review board at Ann & Robert H. Lurie Children’s Hospital of 437

Chicago approved this study on November 19, 2015 (IRB 2016‐120). 438

Disclaimers: none 439

Previous presentations: The first author presented preliminary results of this study at the 440

Behavioral Sciences in Acute Settings Conference in Aberdeen, UK in November 2016. 441

442

443

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Table 1 Participant characteristics

Participant characteristics Proportion of total (n = 17) in absolute numbers

Gender Male (11)

Female (6)

Training level

Residents* (11)

Subspecialty fellows** (5)

Chief resident*** (1)

Training years after graduation

from medical school

i.e. post‐graduate year (PGY)

PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY 6 PGY 7 PGY 8

4 2 5 3 1 1 0 1

Specialty/Training Program

General or subspecialty pediatric programs (10)

Emergency medicine (4)

Orthopedics (1)

Surgery (1)

Internal medicine (1)

*Resident = doctor in a general training program **Subspecialty fellow = doctor in a subspecialty training program ***Chief resident = training program graduate who helps administer training program

Appendix: Interview Guide

A. Opening of the interview (clarify purpose of interview, permission to record)

B. General information (age, specialty, year of training)

C. General opening questions about every day telephone conversations

a. When you think about your daily clinical work, tell me about the work‐related

telephone conversations you have with other health care providers. With whom

do you speak and why?

b. Tell me about the last work‐related telephone conversation. Why did it take

place? Was it typical for you?

c. Describe a recent work‐related telephone interaction with other doctors, nurses,

or allied health professionals that stands out for you. Why does it stand out?

D. Exploring status / power differences between types of conversations partners

a. Do you perceive any differences in the telephone interactions with different

conversation partners? Based on professions? Medical specialty? Supervisory

status?

E. Exploring difference based on who initiates the call

a. Do you perceive any differences in the telephone conversations depending on

who initiates the call?

F. Specific conversational strategies

a. What situations make a telephone conversation challenging for you? How come?

How do you manage these?

G. Summarizing lessons learned

a. What advice would you give to more junior colleagues about managing

telephone conversations with work colleagues more effectively?

b. What are the most important lessons you have learned about managing

telephone conversations with other health care providers, and why?

H. Closing

a. Is there something you did not think of before that occurred to you during this

interview? Anything else you would like to add?

Examples of follow up questions (probes)

Please tell me more

Could you expand on that?

Might you provide an example?

How come?

What makes that aspect a challenge?


Eppich, W., Dornan, T., Rethans, J-J., & Teunissen, PW. (Accepted/In press). “Learning the lingo”: A groundedtheory study of telephone talk in clinical education. Academic Medicine.






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https://pure.qub.ac.uk/portal/en/publications/learning-the-lingo-a-grounded-theory-study-of-telephone-talk-in-clinical-education(aee213ae-7a56-45bc-a403-b45b7e392900).html

Over time**Managing power differentials (through rapport building)

Dealing with pushback (anticipating it, negotiating, holding your ground, addressing concerns)Dealing with uncertainty while embodying trustworthiness (being accurate and succinct while

expressing needs clearly)

“Why you are saying it”“To whom are you saying it”Tailoring the talk based on

the goal of the conversation

“What you say”Rhetoric

Using words/languageBeing organized

Making an argument

Resident/Fellow InterlocutorManaging tensions

Experiencing tensions

Informational contentWhat is being conveyed in

terms of medical knowledge & how to get things done

Social contentWhat is being conveyed in

terms of establishing rapport, expressing collegiality,

conveying respect; “politesse”

“How you say it”

Patient care context

Perceiving power differentials (asymmetries in role and information need)Experiencing pushback (being denied, questioned, or interrupted)

Feeling uncertain (not knowing, not being sure)

Reflects learning over time with repeated telephone interactions**

Figure 1: Tensions promote learning during telephone talk


Eppich, W., Dornan, T., Rethans, J-J., & Teunissen, PW. (Accepted/In press). “Learning the lingo”: A groundedtheory study of telephone talk in clinical education. Academic Medicine.






Download date:21. Dec. 2018

https://pure.qub.ac.uk/portal/en/publications/learning-the-lingo-a-grounded-theory-study-of-telephone-talk-in-clinical-education(aee213ae-7a56-45bc-a403-b45b7e392900).html

Over time**Managing power differentials (through rapport building)

Dealing with pushback (anticipating it, negotiating, holding your ground, addressing concerns)Dealing with uncertainty while embodying trustworthiness (being accurate and succinct while

expressing needs clearly)

“Why you are saying it”“To whom are you saying it”Tailoring the talk based on

the goal of the conversation

“What you say”Rhetoric

Using words/languageBeing organized

Making an argument

Resident/Fellow InterlocutorManaging tensions

Experiencing tensions

Informational contentWhat is being conveyed in

terms of medical knowledge & how to get things done

Social contentWhat is being conveyed in

terms of establishing rapport, expressing collegiality,

conveying respect; “politesse”

“How you say it”

Patient care context

Perceiving power differentials (asymmetries in role and information need)Experiencing pushback (being denied, questioned, or interrupted)

Feeling uncertain (not knowing, not being sure)

Reflects learning over time with repeated telephone interactions**

Figure 1: Tensions promote learning during telephone talk

“learning the lingo”: a grounded theory study of telephone

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