Wigton RS, Patil KD, Hoellerich VL. Fhe effect of feedback in learning clinical diagnosis. M11ed Educ 1986;61:816-22. 5. Veniniga R. Interpersonal feedback: a ...
Improving Feedback for Medical Students in a
Famnily
Medicine Clerkship D.G. WSHITE,
MD
R. TIBERIUS, PhD
To evaluate whether feedback to medical students could be improved by asking teachers to complete a student performance rating form during a family practice clerkship, the authors had students and teachers fill out a questionnaire. Teachers in the intervention group reported observing students more frequently. Students' perceptions of feedback frequency correlated strongly with their ratings of feedback
Y. V. M.
TALBOT, MD SCHIRALLI, MD RIC
KEWT,
BA
EEDBACK BETWEEN THE PHY-
E ^
quality.
sician-teacher and his or her student plays an important role in clinical medical education. In such a setting feedback is defined as information given to a student describing his or her performance, the information intended to be used to guide future performance.' Feedback contributes to clinical learning in two important ways. First, it provides the
Afin d'evaluer s'il etait possible d'ameliorer la retroaction aux etudiants en medecine par un formulaire complete par les professeurs et mesurant la performance de lIetudiant pendant son stage d'externat en medecine familiale, les auteurs ont demande aux etudiants et aux professeurs de repondre a un questionnaire. Les professeurs du groupe d'intervention ont rapporte avoir observe leurs etudiants plus frequemment. On a constate une forte correlation entre la perception des etudiants sur la frequence de la retroaction et la qualite de la retroaction. nan hm ysian 1991;37:64-70.
Dr White is an Assistant Professor and the Director of Undergraduate Education in the Department of Family and Community Aledicine, Faculy of MVedicine, University of Toronto, Ont. Dr Tiberius is an Associate Professor in the Departments of Rehabilitation Medicine and Family and Community Aledicine and a Research Associate at the Centre for Studies in Aledical Education in the Faculty of Aledicine, Universiy of Toronto. Dr Talbot is an Associate Professor and the Director of Research in the Department of Family and Communiy Medicine, Faculty ofMedicine, University of Toronto. Dr Schiralli is an Assistant Professor in the Department of Family and Community AMedicine and is head of the Family Medicine Clerkship at Toronto General Hospital, Toronto. Ms Rickett was a Research Assistant in the Department of Family and Communiy Aledicine, Mount Sinai Hospital, Toronto, at the time of the study. She is currently Health Information Analyst in the Department of Public Health, Toronto, Ont.
* V - V - V - 0 0 - 0 0 0 0 0 & 0 0 0 - 0 - - X X X X X X X X - X X X X - - X
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Family Physician VOL 37: Januagy 1991
trainee with vital information on his or her performance, thereby setting the stage for improvement. ' Studies have shown that improved feedback mechanisms are associated with superior student performance in the acquisition of skills in orthopedic physical examination,2 interviewing,3 and diagnosis of urinary tract infection.4 Second, feedback enhances relationships between teachers and learners and conveys an attitude of concern to emerge for the progress and development of the student. Feedback leads to increased mutual respect, decreased misunderstanding, and greater confidence for the learner. I,) Although feedback is useful to the learner, the quality of feedback is often compromised in clinical settings. Lack of time is one impediment; providing feedback competes with multiple demands on the clinical teacher, such as responsibility for patient care, efficient management of the practice, research, and other educational commitments. These pressures are particularly acute in busy primary care ambulatory settings, where most family practice clinical teaching takes place. The quality of feedback can be compromised in clinical settings also because of the perception or experience of most teachers and learners that the feedback process is emotionally taxing. A final impediment is that teachers often do not prepare themselves to provide feedback by making systematic observations of their students' performances.
An extensive literature review showed no studies of methods to improve the quality and frequency of feedback between clinical teachers and medical students about students' performance on clinical rotations. In fact, some of the impediments to providing feedback are difficult or impossible to change. Many patient care settings have time constraints. Reducing the stress of the feedback process would be time-consuming and costly because it would require teachers to undertake specific training in communication skills. We hypothesized that the impediment of lack of preparation might be removed by a mechanism that would help teachers to make structured observations about their students' clinical activities. We then designed a study to determine whether feedback to students could be improved by asking teachers to complete a behavior-specific rating form of clinical performance to be filled out after each day of student supervision. To assess the quality of a complex interaction, such as educational feedback, it is necessary to measure multiple dimensions of the feedback process. The characteristics of constructive feedback repeatedly emphasized in the literature are sufficiency, specificity, timeliness, regularity, relevance, encouragement, incorporation of recommendations, and reciprocity.""'7 Moreover, both student and teacher perceptions must be measured because they can differ. Gil and colleagues found that medical students' ratings of the quality of feedback were significantly lower than their clinical teachers ratings of the feedback." Both groups agreed on the importance of feedback. We therefore decided to test the impact of asking teachers to complete a daily rating form of student clinical performance by assessing both teacher and student perceptions of a number of feedback variables. We designed similar questionnaires for teachers and students to rate the feedback they gave or received according to the above characteristics. The responses of the group who used the rating forms were compared with the responses of a control group of students and teachers who did not receive rating forms.
METHODS The sample population consisted of fourth-year medical students and their clinical teachers participating in a required 4-week family practice clerkship. A static-group comparison design was used to study the effect of the intervention. This design is useful for studying teaching interventions where randomization or subject pairing is impossible because conditions external to the study dictate student assignments.8 Twenty-nine students and 10 teachers at two university-affiliated family practice teaching sites were assigned to the intervention group. In five other sites, 51 students and 29 teachers were assigned to the control group. Study groups were of unequal size because of differences in student assignments to teaching hospitals. During the family practice rotation each student saw a variety of ambulatory primary care patients under the supervision of family physicians in the teaching center. For each patient seen by the student, clinical supervision included case discussion and teaching. Intervention consisted of asking teachers to complete a brief behavior-specific rating form of student clinical performance each time they supervised a student (Figure 1). Because specificity is an important attribute of feedback, the forms were designed to be distributed and collected daily in order to reflect the teacher's judgment of a specific performance rather than a recollection of the student's general functioning during an entire rotation. The daily rating forms were collected at the end ofthe session whether or not the clinician had made any notation. For both control and intervention groups, the students' and teachers' perceptions of the feedback process were assessed by questionnaire. The students completed their questionnaires at the end of each 4-week rotation and were then asked to rate on a five-point scale their perception of such feedback variables as frequency, timing, clarity, and overall quality. In addition, students were asked to answer questions about their perception of teachers' inierest and knowledge level, teaching setting, and types of clinical problems. The teachers' questionnaire was administered at the end of the 16-week study Canadian Family Physician voI, 37. Januagy 1991
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Table 1. MEASURES OF STUDENT RESPONSES TO FEEDBACK QUESTIONNAIRE
INTERVENTION (N = 29) MEAN
FEEDBACK VARIABLES
FREQUENCY OF FEEDBACK FREQUENCY OF OBSERVATION USEFULNESS TO LEARNING DEGREE OF DETAIL DEGREE OF SPECIFICITY RELEVANCE TO LEARNING TIMELINESS OF FEEDBACK CLARITY OF FEEDBACK TEACHER INTEREST QUALITY OF FEEDBACK STUDENT-TEACHER RATIO TIME AVAILABLE IMPORTANCE OF RESIDENTS VS CLERKS ADEQUACY OF PATIENT PROBLEMS CONSTRUCTIVE CRITICISM TEACHERS' KNOWLEDGE NUMBER OF TEACHERS a
Two-sided t-test
b
Significant at the
