The purpose of this study was to evaluate the efficacy of the use of Crucial Conversations workshops by the University of Ottawa’s faculty of medicine as one strategy to prevent and manage disruptive behaviour. Data were collected using post-workshop quantitative evaluations and qualitative interviews. Nearly all participants agreed that the workshops would help them in their professional life, the skills they learned would help them resolve issues they face in the postgraduate medical education (PGME) environment, and they would recommend the training to colleagues. Participants provided examples of new knowledge and skills they had attained as well as how their communications and behaviour in the workplace had improved. Moreover, participants reported that the workshops had a marked influence on the PGME culture — normalization of engaging in difficult conversations and the emergence of a common language around effective communication. We conclude that the workshops are an effective strategy to address and manage disruptive behaviour in a PGME environment.
The increasing amount of literature and growing professional concern over disruptive behaviour in the postgraduate medical education (PGME) environment has resulted in efforts to enhance education and training for faculty, residents, and staff in this area.1 At the University of Ottawa, one initiative has been the inclusion of Crucial Conversations (CC) workshops2 to promote effective and healthy communication and address and manage disruptive behaviour. Other factors contributing to the introduction of these workshops included increasing sensitivity to cultural shifts in behavioural expectations of learners and health professionals in Ontario3 and implementation of the University of Ottawa Faculty of Medicine Standards of Ethical and Professional Behaviour4 and the College of Physicians and Surgeons of Ontario (CPSO) policy on Physician Behaviour in the Professional Environment.5-6
The purpose of this study was to evaluate the efficacy of the CC workshops as one strategy to assist medical leaders, faculty, residents, and staff to prevent and manage disruptive behaviour in the PGME workplace. Top
Among the requirements for accreditation and certification, Canadian physicians must demonstrate commitment “to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.”7 This commitment involves exhibiting appropriate professional behaviour in practice and recognizing and responding to unprofessional behaviour in physicians and other colleagues in the workplace.8-9 Top
Disruptive behaviour, as defined in the present investigation, refers to, “a pattern of inappropriate conduct that has the potential to negatively impact the workplace and patient safety.”1 It takes many forms: verbal (e.g., personal insults), physical (e.g., unwanted contact), environmental (e.g., gossip), and systemic (e.g., dominating meetings).10-11 Physicians who engage in recurring incidents of disruptive behaviour face an array of consequences, including interpersonal tension, complaints, litigation, discipline, termination of training or privileges, and revocation of licensure.1 Moreover, working in a disruptive environment has been linked to breakdowns in communication, which can lead to sub-optimal performance, medical errors, adverse events, and, ultimately, reduced quality of patient care.11-12Top
Disruptive behaviour can also negatively impact medical learning environments by modeling inappropriate behaviour for students and residents, impeding their ability to acquire clinical skills and undermining collaboration.8 Indeed, a 2012 report suggested that 73% of residents have experienced such disparaging behaviour during residency.13 As many as 5% of physicians demonstrate disruptive behaviour,8 and nearly 25% do not feel comfortable or competent in confronting it in colleagues.1,10 Top
The growing concern over disruptive behaviour has resulted in education and training with a focus on teamwork, communication skills, and conflict resolution.1 For instance, the CPSO and the Ontario Hospital Association co-developed a resource for managing disruptive physician behaviour6 with similar approaches found in the physician health guide from the Royal College of Physicians and Surgeons of Canada.8 However, it is has been recommended that additional in-depth training and resources are needed to address disruptive behaviour within the PGME environment.9Top
The University of Ottawa’s faculty of medicine also identified this need for training.10 Based on selection criterion identified by the university, the CC workshop2 emerged as a program with the required evidence-based, interactive, and structured skill-enhancing curriculum, and several faculty members were trained to facilitate CC workshops. Efforts were made to tailor workshop content to contexts commonly experienced and reported in the PGME environment. The two-day workshop was made mandatory for program directors, program administrators, and chief residents. More recently, this training program has also being offered by several other Canadian health organizations, including the, Ontario Hospital Association,14 the Ontario Medical Association,15 and the Canadian Medical Association.16
In the context of the CC workshop, a “crucial conversation” is a discussion between two or more people in which stakes are high, opinions vary, and emotions run strong.2 Training can help participants resolve disagreements, build acceptance rather than resistance, speak persuasively not abrasively, and foster teamwork.2Top
In this evaluation, the research questions addressed were:
How did participants in the CC workshop describe their experience?
Does the CC workshop contribute to the development of skills to address and manage disruptive behaviour in the PGME workplace?
In general, how can the CC workshop be improved in the future? Top
A mixed-methods research design, contrasting qualitative interview data with quantitative, post-workshop evaluations, was used to address the research questions. The findings were organized under the components of the W(e)Learn framework: content, media (delivery), service, structure, and outcomes.17,18 Its emergent design focuses on program improvement in response to learner feedback.18,19 An interactive version of the framework is available online.20 Top
In all, 78 participants took part in this study. To develop in-depth accounts of participants’ thoughts, attitudes, and experiences regarding the CC workshops, individual interviews were held with a convenience sample of 17 people21 recruited from individuals who took part in the PGME’s CC workshops at the University of Ottawa, between 2010 and 2015. They included three program administrators (PA), four residents (R), eight program directors (PD), and two workshop facilitators (F). Participation was voluntary; interviews lasted 45–60 minutes and were audio-recorded with participants’ consent.
A voluntary, post-workshop evaluation form was distributed to each participant to complete anonymously at the conclusion of each workshop. It assessed participant ratings of the workshops using Likert-scale survey questions (e.g., strongly agree to strongly disagree). Data from open-ended (qualitative) and Likert-scale (quantitative) questions were collected from the 61 post-workshop evaluations that the PGME office had on file from 2010–2015. Top
After each interview recording was transcribed and filtered, a content analysis was carried out.22 Transcripts were read and re-read and an initial list of emerging themes was developed (both from the deductive elements of the evaluation framework and the more open-ended, inductive data) until no new codes or sub-codes emerged. Codes were then regrouped under higher-order themes and sub-themes to obtain information that would answer the research questions.23-24
For the post-workshop evaluation, descriptive statistics were generated from the Likert-scale responses (n = 61) and organized under the components of the W(e)Learn framework: content, media, service, structure, and outcomes. Top
Breadth and depth: Most interviewees felt that the breadth and depth of the content presented in the CC course were acceptable: “I thought it was excellent – very comprehensive, timely, and appropriate to my role as a program director, and my position in the hospital” (PD2).
However, a few thought the content could be condensed and prioritized; they suggested the range of concepts presented to participants limited the depth needed for the audience to effectively assimilate the content. Top
Relevance: Most interviewees stated that the content was very applicable to their work in the PGME environment, in interactions with patients, in an administrative setting, or to facilitate conversations between and among colleagues.
[The workshop] is 100% applicable.… Most of the course was geared toward how to talk to colleagues.… As physicians, that is one of the more challenging parts of our job — actually [interacting in] the work environment, not necessarily patient care. (R1)
Participants also reported that the real-life scenarios helped to reinforce concepts. However, several also noted that additional examples tailoring more of the content to specific PGME audiences would be appreciated.
Finally, several participants stated that the information presented was a transferrable skill set, both in their professional practice and personal life. “It was very practical, and addressed how to manage difficult conversations in all spheres of life — professional and personal. That was my big take-away” (PD3). Top
There were no data from the post-workshop evaluations to support the interview data with regard to content.
Teaching methods: Interviewees unanimously agreed that the CC workshops were interactive. A resident stated: “It was interactive and fun… great, real-life examples to explain the concepts and then incorporating activities” (R4). Contributing to the interactivity was a balance of theory and practice. One participant reported: “It was structured in an educational way with delivery through a variety of methods” (PD1).
Most interviewees reported that the teaching strategies used in the workshops enhanced the learning experience. For instance, sharing with colleagues during the workshop was effective. In the words of one program administrator, “You were able to share with your colleagues who are experiencing the same things ‘This is how I dealt with it,’ but then… we were able to see ‘This is how we should have dealt with it’” (PA1). Top
Similarly, most interviewees reported that the workshops catered to various learning styles, enhancing the quality of the learning experience. One program administrator commented: “It was a good mix… asking for individual responses, but also incorporating group work and self-reflection.… such a range allowed everyone to participate” (PA2).
Facilitators: Facilitators played a major role in determining participants’ perceptions of the overall quality of the CC workshops. Although most thought the facilitators were a strength enhancing the workshops, there was variation in responses regarding their quality and effectiveness. Top
Being knowledgeable about the content was the dominant quality contributing to a facilitator’s effectiveness. One program administrator explained:
[The facilitator] really knew the information… they were able to help. It almost turned into little personal side-sessions during breaks as people approached [them] to [ask about personal contexts] and how to go about approaching them. (PA2)
Similarly, interviewees rated facilitators negatively when they perceived that they were disengaged, did not possess the requisite knowledge to lead the workshops, or if they failed to contextualize content. One resident expressed her concern regarding an ineffective facilitator: “[The facilitator] didn’t give off confidence and several times they took phone calls. This annoyed some of us. They didn’t give that personal feel, and didn’t really make the course [their] own” (R2). Top
Part of being considered knowledgeable was a facilitator’s ability to contextualize the content and concepts by describing real-life PGME experiences and examples. One interviewee explained how relying on personal experience made the facilitators seem more authentic: “The way they described the information was proof that they are actively using those skills in their day-to-day life” (R4). Top
Other descriptors associated with effective facilitation included being adaptable (i.e., modifying cases and learning activities to the specific needs of the demographics of the group), engaging, passionate, enthusiastic, and dynamic. Conversely, ineffective facilitators were associated with an inability to adapt to the needs of the audience, for example, by spending more time on a concept when needed and moving more quickly through another when it was clear the audience already understood the material. Top
Post-workshop evaluation responses related to how content was delivered suggested that “delivery” was an area of strength for the workshop. Most participants (97%) either agreed or strongly agreed that the facilitators were able to contextualize the content, clearly articulated expectations, encouraged discussion through open-ended questions, communicated the concepts clearly, kept the course on time and on topic, and appeared to be knowledgeable about the content. These results reflected those from the interviews, which, with only a few exceptions, included considerable praise for facilitators. Top
Resources: Most interviewees said they appreciated and derived value from the CC materials provided to them during the workshops. One program administrator elaborated: “Sometimes I will bring [those tools] out if I know [a crucial conversation is] forthcoming. I refresh myself on what was delivered at the course” (PA2).
Several interviewees reported that the CC resources were not useful, and they did not use them after the course. For instance, one program director stated: “I recall being made aware of these resources [post-course]. I even tried to go back to some of the tools, but have not found them to be useful” (PD6). Top
The post-workshop evaluation findings suggested that the services provided by the resources were excellent, with 98% of participants agreeing or strongly agreeing that the workshops will help them in their professional life. Similarly, 85% felt prepared to apply the strategies they learned in the workshops; however, 13% only “slightly agreed” with this.
Organization: Most interviewees were pleased with the general organization of the workshops: “It was very well organized… and professionally delivered. This made it appealing to me” (R1). Many also lauded the pre-course organization: Top
The schedule [for the courses] comes out early in the year, so you can sign-up and make sure that we were free for the two days…. We were given the information [for the course] well in advance. That really helped. (PA1)
Group size and demographics were also important aspects of course organization. Having a small-group setup was preferable over a traditional classroom-style arrangement. One program administrator explained: “A small group made it easier to have those practice conversations and to be able to share. It is not as intimidating” (PA1). Other participants said they preferred homogeneous groups: “I didn’t really feel comfortable discussing [my issue] with my partner whom I didn’t know and who was clearly high up in the university.… we all know we have intertwined lives” (PD6). Top
With regard to the structure of the workshops, many of the evaluation respondents agreed or strongly agreed (87%) that the facilities used for the workshops were pleasant, comfortable, and generally conducive to learning, while 13% only slightly agreed with this statement. With respect to the material provided to participants before the workshop, 97% agreed or strongly agreed that they met their needs. These results generally support the interview findings (e.g., learning resources provided).
Transfer of knowledge: Interviewees provided several examples of how they have used the knowledge and skills learned at the CC workshop in their workplace. Several program directors agreed that the workshops provided them with useful strategies and tools to assist with learners in difficulty. Top
One program director explained: “I have used the course for remediation purposes.… Often [for reasons] related to communication skills.… Our residents have found it useful for those who lack insight in communication” (PD6).
Confidence: Faculty, administrators, and residents all reported that the knowledge and skills learned in the CC workshops resulted in increased confidence when initiating difficult conversations: “Setting up that [conversation] is always the most difficult part.… I now don’t feel as intimidated” (PA1). Top
Similarly, one program director suggested that CC empowered residents to stand up for themselves:
[All] residents could really use these skills, not only because many have challenges in communication, but also because they are treated like crap sometimes in certain settings. They feel they have to suck it up and take it.… Learning those skills helps them understand they don’t have to. (PD5)
Residents reported similar results: “Our group [of residents] is definitely more confident in having [difficult] discussions, such as delivering feedback and standing up for ourselves. I noticed others taking initiative as well. It is something that overall has gotten better” (R2). Top
Communication: Several interviewees stated that the workshop helped them improve their awareness of when a crucial conversation was needed and increased their communication skills between and among peers and colleagues. One program director expounded: “One of the main things it [the workshop] does is it makes communications conscious. Actually being able to be conscious of my own communication and how other people are communicating, I found that useful” (PD6).
A resident also acknowledged how being aware of emotions that affect CC has been one of the greatest benefits. “What makes [the conversation] crucial is an emotion on my side and the other person’s side.… now that I am aware and practising, that has been the one that I’ve had to work on the most” (R2). Top
Another reason interviewees gave for improved communication with peers, colleagues, and supervisors in the workplace was a common language they had developed during the CC learning experience. One faculty member testified: “People will say something like ‘you just crucial conversation-ed me,’ or ‘we need to have a crucial’” (F2).
Environment: Interviewees commented that the CC workshops could benefit any individual working within the PGME environment. One resident highlighted: “The skills in this course can singlehandedly change hospital and working environments. There is great potential here for these skills” (R1). Top
Several groups were identified as being able to benefit from the workshops. Although residents were the most commonly cited potential beneficiaries, namely chief and early-year residents, other groups included program directors, administrators, and international medical graduates.
Some went so far as to suggest that the workshops should be mandatory for all involved in PGME — not only program directors and chief residents, as per current practice. One program director stated: “[CC should be] absolutely mandatory. It is very, useful. I could take the course frequently and have it be equally useful every time” (PD3). However, other participants felt that, although the workshops were useful, they should not be mandatory. One resident clarified: “You really only want people that have buy-in and want to do it.… I don’t think making it a mandatory thing would accomplish what you want to accomplish” (R3). Top
Interviewees identified common “crucial conversations” in the PGME environment, the most notable being those between residents, e.g., regarding call schedule and professionalism. Another was between residents and program directors, e.g., not meeting expectations, academic or professionalism issues, evaluations or feedback.
“[The conversation] that happens fairly frequently is having to tell a resident they are not performing up to the expectations of the program” (PD8). Similarly, another program director noted that conversations with residents often became crucial when they “show resistance to or lack of insight into feedback. The stakes are high, opinions are different, and they can get quite emotional.… [Residents] need to be able to understand how to navigate this” (F2). Top
Other common crucial conversations arise in general team settings (e.g., team dynamics in meetings, patient care approach); between residents and program administrators (e.g., rude, disrespectful behaviour from residents); program administrators themselves (e.g., role clarity and task sharing); and with patients and/or their families (e.g., managing expectations).
Finally, participants also noted that CC training is also helpful for physicians in managing difficult conversations with patients and/or their families: “I often encounter [crucial] conversations where a patient wants something very different than I clinically provide or feel is the proper approach” (R3). Top
Follow-up: Interviewees reported that CC is a useful workshop and many said they learned new knowledge and skills, including improved communications and behaviour in the workplace. However, many questioned the long-term use of the CC skill set in relation to attrition of skills over time. One program director suggested:
The “one and done” approach is something we need to re-think in order to make it more effective. Did I learn anything? Have I changed enough from the single course? I think I’ve become a better communicator, but have I really? (PD7) Top
Similarly, interviewees were vocal about how difficult some of the skills presented in the workshops are to master. They commonly stated that proficiency requires ongoing commitment, practice, and effort. “No one is going to have the skill sets ingrained from a one- or two-day workshop. The course introduces the concepts and hopefully sends you on a path to improve yourself, your communication style and so forth” (PD2).
Regarding quantitative outcomes, 91% of evaluation respondents agreed or strongly agreed that the skills they learned will help them solve issues in the PGME environment, and 96% reported they would recommend the CC workshops to co-workers, friends, or family members. These results support several of the findings from the interview data, such as recommending the training to others (e.g., program directors), confidence, and transfer of knowledge. Top
Participants reported that the CC workshops were comprehensive, timely, and at an appropriate level of difficulty for the PGME audience. The range of material may have limited the depth needed to effectively assimilate the content; however, real-life scenarios helped to reinforce concepts. Although most participants said the content was relevant, a few thought it could be more tailored to the PGME audience and contain more context-specific scenarios. Contextualizing cases is extremely important for face validity, learner application, and generalization. The workshops also provided tangible skills needed to address and manage difficult conversations (e.g., around disruptive behaviour) that affect personal and professional relationships, a healthy work environment, and personal health.1,12 Top
Participants unanimously agreed that the teaching strategies enhanced the overall learning experience. Diverse and interactive teaching strategies that provided opportunities for colleagues to share experiences were appreciated and deemed effective. Consultation with colleagues has been cited in other reports as an ideal method of obtaining new information for many medical professionals.25-27 Most participants reported that the workshop catered to different learning styles. Top
Some facilitators were far more effective than others in delivering the same content. Being knowledgeable about the content and able to contextualize the content and concepts by sharing and using real-life PGME experiences and examples, as well as being flexible and adaptable to the environment and audience, were characteristics participants associated with effective facilitation. Less effective facilitators tended to have difficulty adapting to the needs of the audience (e.g., moved too quickly through concepts to keep on-time), were disengaged from the audience, did not convey a sense of knowledge around the content, and largely failed to contextualize the concepts. Top
Participants appreciated and derived value from the resource materials provided (e.g., workbook, CDs, cue cards, web sites) for consultation after the course and to guide future learning and ongoing skill refinement.2,28
Positive outcomes included useful strategies and tools to assist with remediation of residents. Our findings suggest that the training enhanced effective communication within the PGME environment by providing tangible strategies, building confidence, and enhancing self-awareness. Top
The workshops had a marked influence on PGME culture, in terms of normalizing engaging in difficult conversations and the emergence of a common language around effective communication. Some participants provided examples of how they had improved their communications and behaviour in the workplace; however, they agreed that proficiency in these skills requires ongoing commitment, practice, and effort.
The University of Ottawa offers a follow-up course, Crucial Accountability, and a complementary course, Influencer, for those interested in further enhancing their skills.29 However, there is also an appetite for more opportunities for reinforcement and practice, and the PGME should consider developing and implementing more tailored resources to complement those already available to facilitate ongoing skill development. Top
Participants identified a wide range of crucial conversations or scenarios that are common in the PGME environment. Given that putting content into context was an area for improvement for some facilitators, the PGME program might develop a bank of relevant, targeted examples or cases and make it available to future facilitators. The wide range of such crucial conversations identified by the participants also reinforced both the findings of the original needs assessment and reports that all physicians are likely to experience or witness disruptive behaviour in the medical environment.1
CC workshops have helped, and can continue to help, faculty, residents, and administrators build skills to address and manage disruptive behaviour in PGME. It was clear that these workshops should continue to be offered, and the training should remain mandatory for those in positions of leadership (i.e., chief residents and program directors) to create a culture of respect and minimize the negative impact of disruptive behaviour.30 This also resonates with the third edition of the CanMEDS framework, which reinforces the need for medical trainees to develop leadership competencies.31Top
In terms of whether the training should be mandatory for all residents, participants’ views were mixed, although their main rationale was logistic (e.g., time commitment, scheduling) rather than conceptual in nature. Given the reported benefits of CC training in helping to address and manage disruptive behaviour, compounded by the identified need for residents to develop leadership competencies, the costs versus benefits of making the training mandatory for all trainees should be weighed and explored. Top
Although both interviewees and post-workshop evaluations agreed that the CC training had been largely successful, this study was limited to one faculty of medicine over a five-year period. Future research would benefit from replication at multiple sites, as well as exploring the viability of collecting data on rates of disruptive behaviour over time in relation to CC training. Top
Evidence of the usefulness of CC training provided by interviewees was based on personal examples and observations from a limited number of people. Post-study consultation with the University of Ottawa revealed that, since the inception of CC training, there has been a decrease in the number of cases referred to the PGME Professionalism Committee, in the number of communication complaints resulting in dismissal, and in the number of cases proceeding to litigation in the faculty of medicine. However, as no comparison of pre- and post-course levels of complaints and litigation was made, a direct link cannot be established. As such, future study should focus on whether disruptive behaviour in a PGME setting can be reduced after a CC training program is introduced. Top
Participants in the CC workshop at the University of Ottawa enjoyed the experience, felt it was relevant, timely, well delivered, and well organized. An overwhelming majority of participants agreed that the workshop would help them in their professional life and would recommend the training to colleagues. Participants reported that the training enhanced effective communication in the PGME environment by providing them with tangible strategies, building confidence, and enhancing self-awareness. In terms of how CC workshops could be improved, participants suggested developing and implementing more tailored resources to facilitate ongoing skill development, further adapting and tailoring workshops content for PGME-specific audiences, and encouraging workshop facilitators to contextualize concepts by using real-life examples and by being flexible and adaptable to the needs of the audience. Top
Physician leaders play a pivotal role in addressing disruptive behaviour and must be committed to creating a culture of respect within institutions to minimize the negative impact such behaviour can have in the medical training environment. This study highlights that continuing evaluation of CC workshops is critical for design, improvement, and long-term success of the initiative. Finally, it also supports the ongoing commitment of the faculty of medicine, in collaboration with other stakeholders, to implement systemic efforts to reduce disruptive behaviour among physicians. Top
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27.Oshikoya KA, Oreagba I, Adeyemi O. Sources of drug information and their influence on the prescribing behaviour of doctors in a teaching hospital in Ibadan, Nigeria.
30.Collier R. Physician codes of conduct becoming a norm. Can Med Assoc J 2013;183(8):892-3.
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The Office of Postgraduate Medical Education, Faculty of Medicine, University of Ottawa, supported this project financially.
Conflict of interest declaration
Drs. Simon and MacDonald declare no conflict of interest; Dr. Puddester is one of a group of certified trainers in Crucial Conversations at the University of Ottawa and the Ontario Medical Association.
Christopher Simon, PhD, and Derek Puddester, MD, MEd, are on the faculty of medicine at the University of Ottawa.
Colla J. MacDonald, EdD, is a distinguished university professor, emeritus, at the University of Ottawa.