Study design and setting

Multi-center qualitative study, involving Family Medicine professors and residents from the Mexican Republic. The present research was approved by the Research Ethics Committee of the Faculty of Medicine at the National Autonomous University of Mexico (UNAM); registration number: FM/DI/010/2021 and adhered to the SRQR guidelines [21]. The study focused on exploring teacher-resident communication challenges–which included their interactions with peers, the work team, and patients–using the Flanagan’s critical incident technique (CIT) [22]. This technique is considered valuable for understanding significant events related to professionals’ behavior in well-defined situations. Critical incidents do not necessarily involve extreme gravity or life-threatening situations; instead, they encompass occurrences that are surprising, unexpected, or disturbing to the professional, prompting a certain level of analysis [22,23].

Sampling and recruitment

From May 17th to October 11th, 2022, professors and third-year residents in the Family Medicine specialty from various federal entities within the Mexican Republic were invited via e-mail to participate in a Zoom session. Third-year residents were chosen for their tenure in the residency program, which exposed them to a wide range of incidents. The participating professors included associate and full professors with different years of teaching experience. During the sessions, the significance of the research was presented to sensitize, and motivate participants (rapport) [24,25]. We explained aspects of the CIT, communication problems, their effects, and the importance of addressing them. The study methodology was also described.

In these sessions, we emailed all attendees the informed consent form—in Word format—stating that participation was voluntary, anonymous, and would not affect their performance as resident or professors. The consent form detailed the benefits and risks of participating in the study and informed participants of their right to withdraw at any time.

Additionally, participants received Word documents containing questions about sociodemographic data and open-ended questions of critical incidents regarding teacher-resident communication challenges.

The elements that participants were required to address, regarding the critical incidents, are outlined in Table 1.

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Table 1. Elements to be gathered using the CIT.

https://doi.org/10.1371/journal.pone.0310455.t001

At the end of the sessions, attendees were given one week to submit their critical incidents and signed consent forms via e-mail. Only those who chose to participate freely returned the required documents in separate files.

Critical incident formats related to communication problems were included, while duplicate formats, poorly reported or incomplete, were excluded as they did not meet the descriptive elements mentioned in Table 1.

Data collection and analysis

The research team comprised specialists in family medicine (I H-T, ON P-A), teaching experts (I H-T, LF R-H, G L-O), communication specialists (I H-T, ON P-A, LF R-H), and doctors in sciences, and education (G L-O, LF R-H). The obtained formats were independently analyzed according to the academic role (teacher or resident) to identify the most frequent communication problems.

Once the critical incidents that met the inclusion criteria were selected, the information was analyzed based on its content and contribution to each category of analysis. According to the methodology of Hughes [26], the following categories were previously established: organizational communication (related to documentation, information hierarchy, and institutional procedures), assertive communication (including sensitivity, empathy, problem-solving skills, or helpfulness), and effective communication (communication barriers). From the obtained data, an emergent category arose: asymmetric communication, which includes narratives about abuse of power, shouting, rudeness, and humiliating treatment.

To enhance the reliability of our findings and minimize individual biases, we employed investigator triangulation involving all authors. This approach leverages diverse perspectives to enrich the analysis and confirm findings [27]. Initially, each researcher independently reviewed the critical incident reports to confirm categories. We then convened to discuss our findings and resolve discrepancies through collaborative discussion. Subsequent reviews refined these categories and addressed any disagreements. Several meetings were held to resolve the remaining discrepancies and achieve consensus [28,29].

Saturation was reached when no new themes or subthemes were identified [30]; this occurred when 60% of the critical incidents were analyzed. However, the analysis was completed for all critical incidents that met the selection criteria.

Asymmetric communication

Asymmetric communication refers to situations where there is an inequality in power, information, or influence among the parties involved in message transmission. This was prevalent in many identified critical incidents, negatively impacting patient care. Participants reported instances where their medical judgment was doubted by higher-ranking healthcare personnel, leading to delays in patient care. For example:

“In an ongoing medical care shift, I presented a patient to the intermediate emergency area, and they refused to accept her because I was a resident. Despite explaining and justifying why the patient needed to be in that area, they refused to listen, and insisted that the attending physician had to give that indication… This significantly delayed patient care.” (Participant 28. Male resident)

Communication issues in this context even jeopardized patient safety, as reported by a resident:

“During my psychiatry rotation, I noticed that the treatments given by the attending physician were not consistent with the literature, and harming patients… I found a patient with signs of acute coronary ischemia, and three patients had hypertensive crises. I told the physician… he did not give the necessary attention because, for him, I was just a resident lacking experience.” (Participant 01. Female resident)

Asymmetric communication also impacted interactions among residents based on their rank. Inappropriate use of hierarchy justified abuses, creating uncertainty, fostering complicated interactions, and affecting the work environment. “Verbal expressions of superiority by residents of higher grades affected group performance, and work environment.” (Participant 30. Female professor)

Within this category, critical incidents were identified where residents explicitly mentioned being subjected to degrading comments, belittlement, verbal abuse, shouting, mockery, rudeness, and intimidation by professors, attending physicians from other services, or residents of higher grades.

“For instance, the professor blocked me from ’WhatsApp,’ claiming, ’It’s my phone, and I do what I want.’ However, she gives instructions through that media… The physician not only has poor communication with some of us, but she is rude, and threatens to fail me… She laughs at me… I sent her several documents, and she refused to accept them, saying ’I do what I want’…” (Participant 44. Female resident)

In describing these critical incidents, residents expressed feeling humiliated, belittled, and insecure, even expressing a “desire to leave the residency program.” (Participant 17. Male resident)

Assertive communication

Assertiveness plays a crucial role in building positive relationships in work environments. In critical incidents within this category, assertiveness was evident in active listening, empathy, and clarity in message delivery. These skills contributed to establishing channels of communication that facilitated the resolution of situations. “Maintaining this openness prevented the development of situations that could have negatively impacted academic progress during residency” (Participant 5. Male resident).

In critical incidents, the willingness of professors to engage in dialogue and resolve conflicts positively influenced residents’ learning of clinical and communication skills. Assertiveness was crucial in physician-patient interactions, and in providing higher-quality medical services. One participant stated:

“The physician reprimanded us in front of the patient and their family when we didn’t know something, creating distrust in them… I approached him and talked about the doctor-patient relationship and how trust influenced it… and how these actions could harm the institution’s image and the services we provided. The physician understood my point very well, and since that day, he has been correcting us privately.” (Participant 33. Female resident)

Assertive communication in critical incidents helped avoid misunderstandings caused by assumptions. Clearly describing ideas, active listening without prejudice, and efficient message reception were facilitated, promoting better performance:

“I believe that knowing how to listen to the person approaching for support and waiting for them to talk about their issues makes communication flow. It allows us to assess what affects them and provide good guidance on decisions according to the problem.” (Participant 24. Female professor)

Within critical incidents narrated by professors, personal situations affecting the learning of some residents were mentioned. Active, sensitive, and empathetic listening skills helped professors seek joint solutions for the benefit of affected residents:

“The residents were complaining about a colleague, saying they didn’t want to be with her because she was too slow to work. After observing her, I noticed she had vision problems… I approached her to talk about how I could help her, and she said she didn’t have money to buy glasses… I bought them for her and talked to some colleagues to form a study group to support her… After two months of having her glasses, the comments about her performance were positive.” (Participant 2. Male professor)

Detecting situations emotionally impacting students and being empathetic allowed professors “to establish more direct communication to understand problems and seek personalized solutions.” (Participant 53. Female professor)

Organizational communication

Organizational communication is crucial during medical residency since formats, notices, and administrative processes are part of daily life in healthcare services. Critical incidents expressed problems in communication for scheduling academic activities and aspects related to research.

Regarding the latter, several residents expressed difficulties in carrying out their thesis projects due to a need for clearer communication from authorities, and professors regarding institutional formats used to register the protocol with the ethics committees, progress delivery times, and thesis registration with relevant administrative bodies. Lack of communication, and the absence of institutional guidelines led to delays in developing their research projects, impacting knowledge dissemination. Some residents expressed organizational communication problems in this regard:

“I was asked to present a research poster for a conference without prior information or specifications, and with less than 24 hours’ notice; these generated multiple problems… the organization and communication were deficient… it seemed to me that they just wanted to fill spaces in that forum impromptu… it was a disaster in all aspects, and I gained no insights.” (Participant 11. Male resident)

Another common issue in critical incidents was the lack of communication regarding the scheduling of rotations, leading to conflicts, and affecting residents’ learning:

“A student was sent to a rotation in the endocrinology service but was rejected by the attending physician, claiming that he didn’t know anything about the resident, the site, the coordinator, or anyone… The physician said that he was tired, and he didn’t want more students… The resident lost her rotation in the endocrinology service.” (Participant 44. Female professor)

Lack of communication was a frequently recurring event, particularly during vacation and holiday periods. There was no information about the absence of professors, and residents resulted in conflicts affecting interpersonal relationships, as well as academic, and service activities.

“I attended the class scheduled on the calendar… when I arrived, the classroom was empty, no students… I contacted the chief resident of the group, and he informed me that they did not attend because they went to a practice at a teaching center and ’forgot’ to pass the memo.” (Participant 16. Male professor)

The lack of updating administrative procedures or changes in guidelines for specific processes was a common scenario. Some residents stated that neither professors nor attending physicians properly communicated procedures to patients and were not updated in rules and guidelines. This affected medical care, since miscommunicating the administrative requirements for referrals and service validity affected the authorization of medicines; “this could lead to patients going home with incomplete or no doses of medications.” (Participant 21. Female resident)

Effective communication

Effective communication involves the transmission of information in a clear manner, considering the needs of the interlocutor and their context. Some critical incidents highlighted the importance of feedback as an integral part of effective communication in medical education. Participants’ narratives revealed problems caused by delivery relevant dates, and grades, particularly “injustices in grading, even when assessment criteria had been communicated beforehand, leading to dissatisfaction and distance in the [teacher-student] relationship.” (Participant 19. Female professor)

In some critical incidents, the need for professors and residents to understand each other’s perspectives and context was evident. The absence of these aspects led to misunderstandings and tensions in various scenarios. The importance of keeping records and evidence of agreements to make communication more effective was mentioned; this helped prevent conflicts by providing a solid foundation for communication” (Participant 58. Male professor). In some narratives, communication seemed forceful, and ineffective, resulting in unnecessary tensions.

“Due to the absence of a teacher, residents had agreements to miss their rotations… I talked to them and informed that they had to comply the established schedule because, from the beginning, they accepted the residency and agreed to follow the schedules. The residents felt attacked, arguing that they were being asked for too much… Due to my communication, which was very energetic, they took it personally.” (Participant 62. Male professor)

In various critical incidents, it was observed that when regular communication channels were ineffective, they escalated to more tense, and confrontational situations with little chance of future success; this affected teaching work, and made the interaction between teachers and students less enjoyable, negatively impacting the residency environment:

“A resident did not fulfill her academic responsibilities, despite verbal recommendations about the quality of her performance… when I did not see changes, I started drafting academic warnings… The student never told me she had some disabilities (hearing, visual, and motor)… Months later, the student wrote a letter to the institutional authorities requesting a review of grades, arguing discrimination… as a professor, I never established an open communication channel where I asked for her opinion about the situation or if she had any problem preventing her from completing the specialty…” (Participant 23. Female professor)

Effective communication was identified as being able to prevent further problems, even in situations that were harsh and unpleasant for the participants. Showing previous evidence of agreements, allowing those involved to communicate with respect, and presenting solid and reasonable arguments about the course of certain events meant acknowledging mistakes and the possibility of rectifying them, regardless of whether the participants liked it or not.

“On one occasion, we had not submitted our theses on time. The professor, calmly, talked to us about the agreement we had made at the beginning of the school year, where we committed to ourselves to hand in our theses according to the schedule… He showed us the evidence, a document with our signatures that made it clear that we knew when we had to submit our work. At first, we were defensive, but the professor explained to us the importance of agreements… Eventually, we understood that the responsibility was ours…” (Participant 32. Female resident)