View in EDS HTML Full Text PDF Full Text

Necessary but Not Sufficient: Identifying Conditions for Effective Feedback during Internal Medicine Residents' Clinical Education

Saved in:
Bibliographic Details
Title: Necessary but Not Sufficient: Identifying Conditions for Effective Feedback during Internal Medicine Residents' Clinical Education
Language: English
Authors: MacNeil, Kimberley, Cuncic, Cary, Voyer, Stéphane, Butler, Deborah, Hatala, Rose (ORCID 0000-0003-0521-2590)
Source: Advances in Health Sciences Education. Aug 2020 25(3):641-654.
Availability: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 14
Publication Date: 2020
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: College Faculty, Medical Schools, Graduate Students, Medical Students, Feedback (Response), Student Attitudes, Teacher Attitudes, Teacher Student Relationship, Observation, Barriers, Coaching (Performance), Formative Evaluation, Internal Medicine
DOI: 10.1007/s10459-019-09948-8
ISSN: 1382-4996
Abstract: Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents' and 7 faculty members' perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.
Abstractor: As Provided
Entry Date: 2020
Accession Number: EJ1259933
Database: ERIC
Full text is not displayed to guests.
FullText Links:
  – Type: pdflink
    Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwEOMWW6xX6MPYWBk88_ThAAAAAA4TCB3gYJKoZIhvcNAQcGoIHQMIHNAgEAMIHHBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDOQ1vsjsKm3_Qcv1rgIBEICBmY6UzRSKweEXH_MtMdn9qVUOGMNA0Re3QKKsexVgU32ZxgJXESGzuE0educyZgmULK5X0AZvO9IpSwYDnEXAFyS-p-gIuk4vaPkXRh8E4Uglmjzkyv7B3IFN10kL5r1zmvVlvapaX16pJ8efkB1uto_WcNS7XPgQt_y2eoJGiyA0yqP-O_wmYsw3BM4nTt0_fk8H6tNxu4CDdQ==
Text:
  Availability: 1
  Value: <anid>AN0144548116;oak01aug.20;2020Jul15.04:14;v2.2.500</anid> <title id="AN0144548116-1">Necessary but not sufficient: identifying conditions for effective feedback during internal medicine residents' clinical education </title> <p>Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents' and 7 faculty members' perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.</p> <p>Keywords: Feedback; Postgraduate medical education; Work-based assessment; Coaching</p> <hd id="AN0144548116-2">Introduction</hd> <p>Throughout their clinical training, residents may have multiple opportunities to experience feedback with faculty including work-based assessments (WBAs), end-of-rotation summaries of performance and informal conversations during clinical supervision. Yet, despite the potential availability of these feedback opportunities, residents continue to describe receiving limited meaningful feedback (Watling [<reflink idref="bib40" id="ref1">40</reflink>]).There is an urgent need to better understand the relationship between learners' perceptions about the range of feedback opportunities created in clinical programs and the conditions that create meaningful feedback in the clinical workplace (Tekian et al. [<reflink idref="bib34" id="ref2">34</reflink>]).</p> <p>Previous research has started to identify conditions that can be associated with meaningful feedback from learners' points of view. For example, grounding much of the contemporary research on feedback is a socio-cultural worldview that emphasizes relationships between learners and faculty (Watling et al. [<reflink idref="bib42" id="ref3">42</reflink>]; Ramani et al. [<reflink idref="bib30" id="ref4">30</reflink>]). From the relationship perspective, research in clinical education to date has shown that learners are more likely to find feedback effective when it comes from a credible source (Bing-You et al. [<reflink idref="bib4" id="ref5">4</reflink>]; Watling et al. [<reflink idref="bib41" id="ref6">41</reflink>]) and is tailored to the individual learner (Lefroy et al. [<reflink idref="bib22" id="ref7">22</reflink>]). Engaging in direct observation of the learner enhances faculty's credibility as does developing a longitudinal, trusting relationship with the learner (Bates et al. [<reflink idref="bib2" id="ref8">2</reflink>]; Bok et al. [<reflink idref="bib7" id="ref9">7</reflink>]; Cuncic et al. [<reflink idref="bib12" id="ref10">12</reflink>]).</p> <p>Contemporary research in education also positions feedback as key to assessment for learning, because through feedback educators and learners share information that may be useful to learner growth (Hattie and Timperley [<reflink idref="bib19" id="ref11">19</reflink>]; Heritage [<reflink idref="bib20" id="ref12">20</reflink>]). However, a 2017 scoping review found that irrespective of the curricular intervention or assessment tool, feedback for learners in medical education frequently remained nonspecific, limited in amount, focused solely on the positive aspects of performance and lacked an action plan (Bing-You et al. [<reflink idref="bib3" id="ref13">3</reflink>]). Research on assessment for learning suggests that feedback is more effective if it positions learners to have agency over their learning, for example by beginning with learner self-assessment, fostering reflection, co-constructing understanding of the learner's progress or performance, and pushing learners to think about "what's next" for their learning (Hattie and Timperley [<reflink idref="bib19" id="ref14">19</reflink>]; Boud and Molloy [<reflink idref="bib8" id="ref15">8</reflink>]; Lefroy et al. [<reflink idref="bib22" id="ref16">22</reflink>]; Moroz et al. [<reflink idref="bib27" id="ref17">27</reflink>]). The education literature emphasizes that feedback is most effective when it "causes thinking" or creates a dialogue about performance with learners (Nicol and Macfarlane-Dick [<reflink idref="bib28" id="ref18">28</reflink>]; Wiliam [<reflink idref="bib47" id="ref19">47</reflink>]).</p> <p>A socio-cultural worldview on learning also recognizes that institutional and learning cultures influence people and processes in addition to providing the clinical context in which feedback occurs (Watling et al. [<reflink idref="bib42" id="ref20">42</reflink>]; Ramani et al. [<reflink idref="bib30" id="ref21">30</reflink>]). This perspective is eloquently captured in the 'educational alliance' framework which re-conceptualizes feedback as a process of negotiation grounded in a supportive relationship between faculty and learner (Telio et al. [<reflink idref="bib35" id="ref22">35</reflink>]). From this perspective, if assessment for learning is ideally designed to create a learning culture wherein feedback is provided for the explicit purpose of fostering learner growth, then it is critical to understand how opportunities for meaningful feedback are enabled or constrained by the assessment processes as enacted within clinical programs. Emerging theory and research suggest that meaningful feedback is more likely when assessments for learning create opportunities for educators and learners to develop trusting relationships and negotiate meaning about performance (Telio et al. [<reflink idref="bib36" id="ref23">36</reflink>]; Watling and Ginsburg [<reflink idref="bib43" id="ref24">43</reflink>]).</p> <p>While research has identified important conditions that make feedback meaningful, less is understood about how different assessments create opportunities for those conditions to be established. For example, in the current era of competency-based medical education (CBME) and programmatic assessment, it is often suggested that meaningful feedback conversations should have a central role. CBME emphasizes frequent, direct observation of performance combined with feedback, typically in the assessment for learning format of WBAs (Frank et al. [<reflink idref="bib13" id="ref25">13</reflink>]; Harris et al. [<reflink idref="bib17" id="ref26">17</reflink>]). The intent is that the low-stakes nature of frequent observations will foster meaningful feedback conversations in an assessment for learning paradigm (Schuwirth and van der Vleuten [<reflink idref="bib32" id="ref27">32</reflink>]). However, studies examining learners' perceptions of programmatic assessment highlight that learners may conceptualize all assessment as summative and have difficulty engaging with meaningful feedback in this context (Bok et al. [<reflink idref="bib6" id="ref28">6</reflink>]; Harrison et al. [<reflink idref="bib18" id="ref29">18</reflink>]; Schut et al. [<reflink idref="bib31" id="ref30">31</reflink>]). There may be an important gap between our intentions (i.e., to generate a feedback culture using assessments for learning) and possible outcomes (e.g., creating assessments in which learners do not perceive feedback to be meaningful).</p> <p>Coaching models for clinical education, which maintain a developmental focus on learner growth, de-emphasize summative judgments and adhere to many of the principles of effective feedback outlined above, may offer an alternative approach to creating opportunities for meaningful feedback in the workplace (Watling et al. [<reflink idref="bib42" id="ref31">42</reflink>]; Voyer et al. [<reflink idref="bib39" id="ref32">39</reflink>]; Lovell [<reflink idref="bib23" id="ref33">23</reflink>]; Stigt et al. [<reflink idref="bib33" id="ref34">33</reflink>]). We have previously investigated how meaningful feedback conversations were fostered through coaching in an internal medicine residency training program (Voyer et al. [<reflink idref="bib39" id="ref35">39</reflink>]). Our coaching program was intentionally based on the principles of establishing a longitudinal relationship between resident and faculty and emphasized direct observation of performance. Importantly, the coaches focused solely on the resident because they did not also have responsibility for patient care, and the coaching program was divorced from summative assessment. When asked to describe their experiences of feedback in the program, residents explicitly linked each of the four conditions we established to their perception of feedback as meaningful (Voyer et al. [<reflink idref="bib39" id="ref36">39</reflink>]).</p> <p>The current study was designed to investigate whether and how conditions for meaningful feedback are being enabled or limited by the kinds of feedback opportunities that are available during clinical education. To that end, we examined residents' and faculty members' perceptions of feedback within one internal medicine residency training program that created feedback opportunities both as part of formalized assessments (WBA, in-training assessment) and through different kinds of coaching relationships (coaching program, clinical supervision). By identifying conditions that led residents and faculty to experience feedback as more or less meaningful across these various feedback opportunities, this study has the potential to advance understanding about how to support clinical education in a competency-based era.</p> <hd id="AN0144548116-3">Method</hd> <p>We employed a qualitative case study design to investigate participants' perceptions of feedback as situated in a particular context (an internal medicine post-graduate clinical education program) that was bounded by time (1 year of residents' post-graduate training) and place (a western Canadian university) (Merriam [<reflink idref="bib25" id="ref37">25</reflink>]; Yin [<reflink idref="bib48" id="ref38">48</reflink>]). Case study methodology allowed us to examine residents' perceptions of feedback anchored within its real-world context (Butler and Cartier [<reflink idref="bib10" id="ref39">10</reflink>]; Yin [<reflink idref="bib48" id="ref40">48</reflink>]). Through our investigation, we sought to build understanding about <emph>how</emph> and <emph>why</emph> assessment opportunities in our internal medicine residency program were (or were not) "working" to create conditions for feedback perceived by participants as meaningful (Yin [<reflink idref="bib48" id="ref41">48</reflink>], p. 4). This study was reviewed and approved by the University of British Columbia's (UBC) Behavioural Ethics Review Board.</p> <p> <emph>Setting</emph> The UBC internal medicine residency program is a large, primarily urban 3-year training program which accepts approximately 50 residents each year. Residents rotate through 4-week rotations at three tertiary urban hospitals and less frequently through community-based sites dispersed throughout the province.</p> <p> <emph>Participants</emph> In 2013, 26 out of 50 post-graduate year 1 (PGY-1) residents in the UBC internal medicine residency program volunteered to participate in this research. Participation included engaging in the coaching program (described below) as well as providing data for collection and analysis. All residents who requested coaching also chose to participate in the research study. In addition to the 3 co-investigators who had designed and implemented the original program, 7 additional faculty were recruited as coaches given their status as clinical educators in educational leadership roles and their reputations as effective clinical teachers. Many were completing or had completed a Master's level degree in Health Professional Education.</p> <hd id="AN0144548116-4">Feedback opportunities within the internal medicine residency program</hd> <p>Below, we briefly describe the feedback opportunities which existed in the residency training program during our study year.</p> <p> <emph>Coaching Program</emph> Intentionally building on principles of effective feedback, the coaching program was designed to create space and time for one consistent faculty member to directly observe, and provide immediate feedback on, a resident's clinical performance over multiple occasions across one academic year without any associated summative assessment (Voyer et al. [<reflink idref="bib39" id="ref42">39</reflink>]). Faculty were freed to focus on the learner as they were not the resident's clinical supervisor. Resident participation in the coaching program was voluntary.</p> <p>Prior to the first observation, faculty-resident pairs (1:3 faculty-resident ratio) met to become acquainted, discuss the program, and discuss learning goals that might serve to focus the observations. Faculty-resident pairs were expected to schedule 3–4 observations of at least 1 hour, during any clinical rotation, over the academic year. Each observation was to begin with a conversation about current learning goals and the focus for observation, followed by the observation period itself and a feedback conversation centered on developing a plan of action and setting new learning goals.</p> <p> <emph>Clinical Supervision</emph> Residents' day-to-day clinical work was supervised by attending physicians who were expected to both supervise clinical care and support resident learning. Each rotation was typically 4 weeks long and residents rotated between hospital sites and across various settings including in-patient and outpatient general internal medicine and subspecialty rotations. Direct observation of performance and informal feedback conversations between supervisors and residents were encouraged by the training program.</p> <p> <emph>Mini</emph>-<emph>clinical evaluation exercise (mini</emph>-<emph>CEX)</emph> At the time of this study, the mini-CEX had been implemented in the residency program for over 5 years. Twice yearly, residents were expected to be directly observed in one or more aspects of a real patient clinical encounter for 15–30 min (Norcini et al. [<reflink idref="bib29" id="ref43">29</reflink>]). Mini-CEXs were conducted by trained faculty who were asked to provide feedback on the resident's observed performance and complete a standardized mini-CEX assessment form.</p> <p> <emph>In</emph>-<emph>training evaluation report (ITER)</emph> Attending physicians typically completed ITERs as a summative assessment at the end of each rotation. The ITERs, which have been used in the training program since its inception, include numeric rating scales assessing each of the CanMEDS domains, free-text comments and an overall global rating (Turnbull and Van Barneveld [<reflink idref="bib37" id="ref44">37</reflink>]). While the aspirational goal was for feedback conversations at the mid- and end-points of the rotation, in reality faculty often completed the ITER at a much later date without a prior conversation. ITERs and mini-CEXs were also reviewed during semi-annual performance reviews with a residency program director.</p> <p> <emph>Data collection</emph> Consistent with a case study design, multiple sources of evidence were collected and coordinated to inform understanding about faculty and resident perceptions of feedback across the coaching program, clinical supervision, mini-CEX, and ITER(Yin [<reflink idref="bib48" id="ref45">48</reflink>]). To establish a description of the assessment modalities and decipher how they were intended to be used by educational leaders within the residency program, we collected documentation including formal programmatic feedback/assessment protocols and descriptions of tools. We also reviewed program documents associated with the coaching program (Yin [<reflink idref="bib48" id="ref46">48</reflink>]).</p> <p>To understand faculty and resident perceptions of feedback, we again relied on multiple, complementary sources of information. First, to support understanding of participants' experiences within coaching sessions, we asked resident-coach pairs to audio-record introductory conversations and exit interviews. Not all resident-faculty pairs generated equal amounts of information. Thus, data available to us from this source included audio-recordings of 4 introductory conversations between faculty-resident pairs and exit interviews with 3 residents. The introductory conversations were intended to facilitate relationship building and to provide faculty with the opportunity to understand residents' experiences of feedback prior to participating in the coaching program. Residents' semi-structured exit interviews were undertaken by their coach. While these materials were certainly shaped by the resident-coach relationship, they were generated in context and in that respect provided useful evidence of some residents' experiences with feedback in the program.</p> <p>Second, all residents were invited to participate in a focus group interview conducted by an educational researcher (DB) with whom they had no educational or professional relationship, to ensure that residents could express their opinions freely. To accommodate diverse schedules, we held 4 focus group meetings which were audio-recorded (n = 19). Both exit interview and focus group questions were designed to explore residents' perceptions and experiences of feedback, learning, and assessment across the variety of feedback opportunities encountered during residency training.</p> <p>To complement the resident data, we also conducted and audio-recorded exit interviews with each of the 7 new faculty coaches. Given her ability to lead a more contextualized discussion, and in order to maintain consistency across interviews, these interviews were conducted by one of the investigators (CC) who had originated the coaching program. The exit interviews focused on faculty's experiences of providing feedback in all assessment contexts.</p> <p>Audio-recordings were transcribed and de-identified by a research assistant not directly part of the research team, prior to being viewed by the researchers.</p> <p> <emph>Reflexivity</emph> The research team intentionally included both insiders and outsiders to the clinical training environment. The three internal medicine clinical educators (CC, RH, SV) who developed the coaching program brought perspectives from clinical training as well as from cognitive psychology and socio-cultural theory. The two PhD educational researchers (DB, KM) brought additional expertise in learning and formative assessment, as well as expertise in case study methodology.</p> <p> <emph>Data analysis</emph> To begin our analysis, all team members read transcripts from introductory conversations, exit interviews and focus groups and recorded memos (Miles and Huberman [<reflink idref="bib26" id="ref47">26</reflink>]), guided by our research focus on understanding how faculty and residents were perceiving feedback within different feedback opportunities (Merriam [<reflink idref="bib25" id="ref48">25</reflink>]). We met to cross-reference our memos and start to develop tentative conceptual understandings and patterns. Next, to rigorously check our emerging interpretations against the data, one educational researcher (KM) led the fine-grained coding of the findings. She began by developing low inference codes (i.e., codes using language close to that used by participants) to systematically capture participants' responses and brought data to the team in order to test and revise our emerging codes and overarching categories. In later stages, KM drew codes into displays that included sources of direct quotation, in order to visually represent information in an organized and compressed form (Miles and Huberman [<reflink idref="bib26" id="ref49">26</reflink>]) and to facilitate our ability to interpret patterns of participants' common and divergent perspectives. Our iterative process moved back and forth between developing conceptual understandings at large group meetings, and fine-grained analyses of interviews and focus groups to construct, test, review, revise, and organize codes (Merriam [<reflink idref="bib25" id="ref50">25</reflink>]). Throughout this process, we attended to both deductive and inductive analysis in order to decipher meaning related to our research focus. In parallel, we examined program documents and descriptions of tools to understand the programmatic context in which this case study was situated, as well as the intended qualities of the different feedback opportunities. Ultimately our analysis process enabled us to identify connections participants were making between the quality of conditions established within different feedback opportunities and their perceptions of feedback utility.</p> <hd id="AN0144548116-5">Results</hd> <p>We first give an overview of residents' perceptions of the affordances for meaningful feedback provided by each kind of feedback opportunity (coaching program, clinical supervision, mini-CEX, ITER). Then, we outline patterns related to residents' perceptions of the key conditions that supported meaningful feedback experiences. We conclude with the faculty perspective. Throughout, we support our interpretations by including illustrative quotes as examples.</p> <hd id="AN0144548116-6">Feedback opportunities</hd> <p> <emph>Coaching Program</emph> The coaching program explicitly included direct observation of performance, feedback grounded in a year-long trusting relationship with faculty, and a focus on residents' learning rather than summative evaluation. Of all of the feedback opportunities we studied, residents most consistently perceived the coaching program as facilitating meaningful feedback conversations. The residents valued that faculty were there to focus on them as learners. However, the coaching program was not without challenges. For example, the provision of feedback was dependent on each coach-resident pair negotiating their busy schedules to generate meaningful feedback opportunities in clinical contexts. Residents' experiences were highly variable as two pairs failed to meet at all and a few met only once or twice. On occasion, there were no clinical encounters to observe and the encounter was described as 'awkward'.</p> <p> <emph>Clinical Supervision</emph> Residents reported infrequently engaging in feedback conversations tied to their day-to-day clinical practice. They explained that clinical supervisors had few opportunities to observe them or provide feedback. Instead, supervisors typically had only a 'snapshot' of resident performance and did not engage in direct observation. Residents described feedback conversations as vague and non-specific. On the rare instances in the data when feedback from clinical supervisors was perceived as meaningful, residents described a conversation that was based on direct observation and that was held with a supervisor with whom they had a longer-term relationship (i.e. more than just a few days of supervision).</p> <p> <emph>Mini</emph>-<emph>CEX</emph> While mini-CEX assessments were designed to provide feedback based on direct observations, residents perceived the mini-CEX to be constrained by the checklist style feedback that resulted from the interaction and, as such, most often described it as not being an opportunity for meaningful feedback. Residents also described instances where direct observation did not occur and resulting evaluations were 'fudged'. However, a few residents described positive learning outcomes, if the educational approach of the faculty included direct observation, focused on the resident's learning, and if the feedback conversation developed an action plan for improvement.</p> <p> <emph>ITER</emph> Residents experienced the ITER as a reassuring measure of their progress and achievement, but they frequently did not perceive it as a meaningful feedback opportunity. It was largely viewed by residents as an evaluative "report card" given the temporal distance between observations and feedback, the checklist style of feedback, and its summative role in their training. When the ITER was perceived as facilitating meaningful feedback, this typically was in the context of a face-to-face discussion between resident and faculty.</p> <hd id="AN0144548116-7">Key conditions contributing to meaningful feedback</hd> <p>Across these different feedback opportunities, residents consistently described certain key conditions that they associated with more meaningful feedback, including direct observation of authentic clinical practice, repeated observation of performance over time, framing the opportunity as about their learning and grounding the feedback in an interpersonal relationship with faculty.</p> <p> <emph>Direct observation of authentic clinical practice</emph> Across opportunities, direct observation of real-world day-to-day clinical practice was highly valued as supporting meaningful feedback. Direct observation of authentic clinical practice was intentionally designed into the coaching program, and, albeit less frequently, was also reported with each of the other feedback opportunities. According to residents, direct observation yielded productive conversations that had the potential to support learning and development.</p> <p>I had Dr. X for the first [mini-CEX]. She was excellent. She just observed me during a consult and was, like, 'Do what you normally do. I'm just going to see what you do and then give you some feedback.'...and she gave me good feedback based on what I'm actually doing (FG 1).</p> <p>This same resident went on to contrast this experience with a subsequent mini-CEX in which the purpose of the observation and assessment was less clear.</p> <p>He asked me to perform a resp (sic) exam, and then he stood there with his clipboard, like, checking boxes. And I was, like, 'Um, do you want me to do this as well?' And I was just asking him questions more like as an exam as opposed to feedback for me. (FG 1).</p> <p> <emph>Repeated longitudinal observation of performance</emph> Residents found the yearlong repeated observations in the coaching program were supportive of positive feedback experiences. But they also indicated that they benefitted from feedback that was based on even 1 month's progress during clinical supervision. Residents attributed the benefits of repeated longitudinal observations to the feedback provider's opportunity to remark on progress over time.</p> <p> <emph>Feedback focused on resident learning</emph> Residents were sensitive to the expressed or covert purpose of feedback across feedback opportunities. They were more likely to describe feedback as helpful when they perceived that the primary purpose of the feedback exchange was for their learning or development rather than as a judgment for a "report card". For example, one resident described a clinical supervisor who:</p> <p>...took the mini-CEX very seriously and he thought very hard about the case I was going to see. We went up together. I saw the patient. He observed me doing it, asked me good questions about it after, it taught me. And I've had ones where I'm on a busy rotation and it just has to get done and they're, like, well, I've seen you examine plenty of patients. So, let's just quickly see someone and I'll fill out the form...depending on those two things it can be—obviously be better learning or worse learning (FG 3).</p> <p>Residents also found it helpful when feedback was specific and helped them identify how to move forward in their development. They found it useful to be reassured that what they were doing was 'working' and given the feedback to continue to do it in the future. That being said, residents also expressed frustration when they were given positive, but not constructive, feedback. For example, one resident explained, "Even if I'm doing well on a rotation, there's clearly a ton of things I could do a lot better and I want to hear about them" (FG 3).</p> <p>When asked about their experiences, residents often couched their responses with a statement about how feedback interactions varied greatly and were "completely staff dependent". While they had many examples of faculty treating formal assessments as "hoops to jump through" or a "burden", they also had positive experiences where other faculty using the same assessment tools viewed the feedback interactions as learning opportunities. In one example, a resident learned with a clinical supervisor who embedded pre-readings into the mini-CEX in order to create a robust opportunity for applying new knowledge.</p> <p> <emph>Attending to interpersonal or relational issues</emph> Residents made links between their variable experiences of feedback and facets of an individual faculty member's investment in their role as an educator. For example, residents made connections between faculty who were "invested", "enthusiastic", "non-judgmental", and "respectful" and positive learning experiences.</p> <p>P1: I don't think the staff necessarily need a CEX to act on that opportunity [to observe and give feedback] 'cause it's always available, right. And that's I think what Dr. J does every block. She takes some time to just observe every house staff. P2: Yeah, I think it's kind of like the staff who are going to do that and take that time, they do it regardless. And the staff who aren't, the CEX is very much a burden (FG 1).</p> <p>Residents also described how the nature of the relationship between resident and faculty can impact the credibility of feedback.</p> <p>I think pre-existing relationship is the most important thing...I find that's the stuff that really matters. If you worked for 2 weeks with someone or they've been your senior resident for a month, then you take what they've said very, very seriously as opposed to if they're just meeting you for an hour. It's a little bit hard without a pre-existing knowledge of one another (FG 2).</p> <hd id="AN0144548116-8">Faculty perspective</hd> <p>In many ways, the faculty's perspective on meaningful feedback mirrored the residents' comments. In terms of affordances, faculty found that the coaching program provided the most salient opportunities to engage in meaningful feedback compared to formal assessment moments such as the mini-CEX or ITERs.</p> <p>...but I actually like it better 'cause I think that there's–getting rid of the boxes actually allows a lot more–because it's not about meets or exceeds. It's about–this is feedback on how you might do this differently or–so it's real. Like, it's authentic–again, as I said, authentic (KN).</p> <p>Faculty also identified similar conditions for meaningful feedback which were most prominent in the coaching program: time for direct observation, a longitudinal relationship with the resident, and creating time to focus the feedback opportunity on learning as opposed to using it summatively. "There's very few opportunities where you have just very– completely devoted time where you can just observe. I think that's the main thing, is just the time" (QX).</p> <p>Through participation in the coaching program, faculty described becoming sensitized to other opportunities for meaningful feedback. For example, one faculty member reflected on the coaching program's influence on their clinical supervision:</p> <p>I have thought about that I should try to incorporate some direct observation at least maybe once or twice a week or whenever I can with the residents. I think it would be useful. I know I think the residents would like it (IO).</p> <p>Unique to the faculty's perspective was the insight that not being the patient's primary provider, as was the case in the coaching program, freed the faculty to embrace their role as educator, as expressed by this faculty member:</p> <p>It really helped because I was less concerned about owning the patient problem, and I could be all about the resident. So I think that did help (XD).</p> <hd id="AN0144548116-9">Discussion</hd> <p>Resident and faculty perspectives on feedback opportunities within our internal medicine residency program revealed that a range of feedback opportunities could be impactful if they fostered certain conditions: grounded in direct observation that was repeated and longitudinal, embedded in a relationship between faculty and resident and focused on supporting residents' learning. These insights are consistent with current conceptualizations of effective feedback in the clinical workplace (Boud and Molloy [<reflink idref="bib8" id="ref51">8</reflink>]; Lefroy et al. [<reflink idref="bib22" id="ref52">22</reflink>]; Telio et al. [<reflink idref="bib35" id="ref53">35</reflink>]) as well as the findings from our prior implementation of the coaching program (Voyer et al. [<reflink idref="bib39" id="ref54">39</reflink>]). While our data confirms previous research as to what enables meaningful feedback, it extends our understanding of how and why these conversations are inhibited by assessments commonly encountered during residency training. If one intent of including assessments for learning in a training program is to increase opportunities for meaningful feedback, our data emphasize that ensuring these assessments create conditions for meaningful feedback is challenging but necessary.</p> <p>Assessment processes and tools provide affordances that shape the conditions for feedback (Ajjawi and Higgs [<reflink idref="bib1" id="ref55">1</reflink>]; Urquhart et al. [<reflink idref="bib38" id="ref56">38</reflink>]). For example, when examining faculty perspectives on how the mini-CEX may be implemented to foster meaningful feedback, Bok et al. ([<reflink idref="bib5" id="ref57">5</reflink>]) found that direct observation was crucial, a relationship with the students facilitated the observations and feedback, and verbal feedback allowed for more fulsome discussion. When the mini-CEXs were used for summative purposes, the student and faculty perspectives shifted away from learning and feedback and towards completing the required number of assessments (Bok et al. [<reflink idref="bib5" id="ref58">5</reflink>]). This finding highlights the tension between formative and summative assessment and encourages us to attend to the affordances for both, concurrently. As the evidence for the mini-CEX illustrates, an assessment tool designed to encourage effective feedback can be undermined when the conditions for feedback are overlooked and summative elements are emphasized. In our case study, the mini-CEX and the ITER more often inhibited meaningful feedback due, in part, to their summative intent. For some faculty, these assessment tools' 'tick boxes' were perceived to undermine authentic interactions with residents. Furthermore, scheduling challenges, lack of opportunities for observation and divided responsibilities between patient care and supervision further constrained meaningful feedback during these assessments. Using a framework such as Polarity Thinking™, which encourages a 'both-and' mindset as opposed to 'either-or' thinking, may be helpful in navigating the tension between the summative and formative intents of the mini-CEX (Govaerts et al. [<reflink idref="bib16" id="ref59">16</reflink>]).</p> <p>In contrast to the WBAs, our data suggests that creating opportunities where faculty have the time and availability to directly observe a resident, in the context of a longitudinal relationship, and with a focus on supporting resident learning, may facilitate the provision of meaningful feedback during residency training. In our study, these conditions were created by integrating a coaching program into our clinical training program. By creating these conditions, the faculty's primary focus seemed to shift from patient to resident, which may have freed them from feeling time-pressured and allowed them to preserve the resident's independence and agency by not feeling an imperative to intervene (Watling et al. [<reflink idref="bib44" id="ref60">44</reflink>]). The faculty's perspective was that having the time to directly observe residents without being primarily responsible for patient care provided them with the space to have learning-focused feedback conversations. By experiencing meaningful conversations under these conditions within the coaching program, faculty developed intentions to re-create some of the conditions during their more typical ward-based clinical supervision.</p> <hd id="AN0144548116-10">Limitations</hd> <p>The current study is not without limitations. We examined feedback opportunities at a single institution in a single training program, with a group of participants who were motivated to participate in a coaching program. The ways in which the specific assessment tools and clinical supervision were enacted may have elements unique to our center and to the specialty of internal medicine. Three of the authors were also coaches who have positive perspectives on the coaching program. We tried to mitigate this by maintaining diverse perspectives in data collection and analysis. All resident focus groups were conducted by an educational researcher (DB) and a different educational researcher (KM) led data analysis. While all participating faculty were asked to undertake an exit interview with the residents they coached, only 4 faculty-resident pairs did so, limiting any insider insights that faculty interviewers could have provided. In spite of these limitations, the themes we identified were consistently evidenced in all data sources and from the perspectives of both residents and faculty. Findings were also similar whether they were generated by coaches or by educational researchers external to the team and as interpreted by team members from multiple positionalities.</p> <hd id="AN0144548116-11">Implications for educational practice</hd> <p>Given the current emphasis on increased WBAs in the era of CBME, there are significant implications from our findings. First, meaningful feedback conversations are attainable in clinical education across a variety of common WBAs, if key conditions are fostered. Second, we cannot emphasize strongly enough that if the intent is to use assessments formatively, our emphasis should not be on the assessment tool but rather on creating the conditions for meaningful feedback and deciding if any tool is required or is fit for purpose. One of the most important 'conditions' or resource are the faculty who are engaging in the assessment; if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning, the feedback conversation is likely to be perceived as meaningful to the resident. Our findings speak to the particular potential of a coaching program in terms of generating opportunities for meaningful feedback, but both residents and faculty described how these conditions can be obtained across other kinds of feedback opportunities. While the mini-CEXs and ITERs were not commonly found to foster meaningful feedback, when they were implemented with consideration of the key feedback conditions, they were able to support them. This is consistent with studies on both mini-CEXs (Malhotra et al. [<reflink idref="bib24" id="ref61">24</reflink>]; Weller et al. [<reflink idref="bib46" id="ref62">46</reflink>]; Castanelli et al. [<reflink idref="bib11" id="ref63">11</reflink>]) and ITERs (Ginsburg et al. [<reflink idref="bib14" id="ref64">14</reflink>]) and highlights the tension between feedback and assessment (Watling and Ginsburg [<reflink idref="bib43" id="ref65">43</reflink>]).</p> <p>An unintended consequence of using any assessment tool for summative purposes is that residents may engage in a staged performance (Bok et al. [<reflink idref="bib6" id="ref66">6</reflink>]; LaDonna et al. [<reflink idref="bib21" id="ref67">21</reflink>]). Our results suggest that feedback in clinical education is most meaningful when the intent is to support resident learning in the context of real-world clinical practice, which in our study and in others' (Bok et al. [<reflink idref="bib6" id="ref68">6</reflink>]; Schut et al. [<reflink idref="bib31" id="ref69">31</reflink>]) is typically at odds with summative use of the assessment moment. One potential solution is to create specific opportunities in which feedback is divorced from formal assessment, as in our coaching program. There is precedence for such an approach in other health professions, most notably the clinical educator role in nursing (Brennan and Olson [<reflink idref="bib9" id="ref70">9</reflink>]). Taking such an approach in clinical education would have the potential to untie the 'Gordian knot' of feedback and summative assessment (Gordon [<reflink idref="bib15" id="ref71">15</reflink>]; Weinstein [<reflink idref="bib45" id="ref72">45</reflink>]). In the current era of CBME, it behooves us as educators to carefully consider our educational opportunities (including assessment moments) and determine whether or not we are truly creating conditions for meaningful feedback.</p> <hd id="AN0144548116-12">Funding</hd> <p>This work was supported by a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.</p> <hd id="AN0144548116-13">Acknowledgements</hd> <p>The authors thank the participating residents and faculty for their participation in this study.</p> <hd id="AN0144548116-14">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0144548116-15"> <title> References </title> <blist> <bibl id="bib1" idref="ref55" type="bt">1</bibl> <bibtext> Ajjawi R, Higgs J. Learning to reason: A journey of professional socialisation. Advances in Health Sciences Education. 2008; 13; 2: 133-150</bibtext> </blist> <blist> <bibl id="bib2" idref="ref8" type="bt">2</bibl> <bibtext> Bates J, Konkin J, Suddards C, Dobson S, Pratt D. Student perceptions of assessment and feedback in longitudinal integrated clerkships. Medical Education. 2013; 47; 4: 362-374</bibtext> </blist> <blist> <bibl id="bib3" idref="ref13" type="bt">3</bibl> <bibtext> Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for learners in medical education. Academic Medicine. 2017; 92; 9: 1346-1354</bibtext> </blist> <blist> <bibl id="bib4" idref="ref5" type="bt">4</bibl> <bibtext> Bing-You RG, Paterson J, Levine MA. Feedback falling on deaf ears: Residents' receptivity to feedback tempered by sender credibility. Medical Teacher. 1997; 19; 1: 40-44</bibtext> </blist> <blist> <bibl id="bib5" idref="ref57" type="bt">5</bibl> <bibtext> Bok HGJ, Jaarsma DADC, Spruijt A, van Beukelen P, van der Vleuten CPM, Teunissen PW. Feedback-giving behaviour in performance evaluations during clinical clerkships. Medical Teacher. 2015; 38; 1: 88-95</bibtext> </blist> <blist> <bibl id="bib6" idref="ref28" type="bt">6</bibl> <bibtext> Bok HGJ, Teunissen PW, Favier RP, Rietbroek NJ, Theyse LFH, Brommer H. Programmatic assessment of competency-based workplace learning: When theory meets practice. BMC Medical Education. 2013; 13; 1: 123</bibtext> </blist> <blist> <bibl id="bib7" idref="ref9" type="bt">7</bibl> <bibtext> Bok HGJ, Teunissen PW, Spruijt A, Fokkema JPI, van Beukelen P, Jaarsma DADC, van der Vleuten CPM. Clarifying students' feedback-seeking behaviour in clinical clerkships. Medical Education. 2013; 47; 3: 282-291</bibtext> </blist> <blist> <bibl id="bib8" idref="ref15" type="bt">8</bibl> <bibtext> Boud D, Molloy E. Rethinking models of feedback for learning: The challenge of design. Assessment and Evaluation in Higher Education. 2013; 38; 6: 698-712</bibtext> </blist> <blist> <bibl id="bib9" idref="ref70" type="bt">9</bibl> <bibtext> Brennan J, Olson EL. Advancing the profession. Nursing. 2018; 48; 10: 53-54</bibtext> </blist> <blist> <bibtext> Butler DL, Cartier SCSchunk D, Greene J. Case studies as a methodological framework for studying and assessing self-regulated learning. Handbook of self-regulation of learning and performance. 20182: NY; Routledge: 352-369</bibtext> </blist> <blist> <bibtext> Castanelli DJ, Jowsey T, Chen Y, Weller JM. Perceptions of purpose, value, and process of the mini-clinical evaluation exercise in anesthesia training. Canadian Journal of Anaesthesia. 2016; 63; 12: 1345-1356</bibtext> </blist> <blist> <bibtext> Cuncic C, Regehr G, Frost H, Bates J. It's all about relationships: A qualitative study of family physicians" teaching experiences in rural longitudinal clerkships. Perspectives on Medical Education. 2018; 7; 2: 100-109</bibtext> </blist> <blist> <bibtext> Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR. Competency-based medical education: Theory to practice. Medical Teacher. 2010; 32; 8: 638-645</bibtext> </blist> <blist> <bibtext> Ginsburg S, Eva K, Regehr G. Do in-training evaluation reports deserve their bad reputations? A study of the reliability and predictive ability of ITER scores and narrative comments. Academic Medicine. 2013; 88; 10: 1539-1544</bibtext> </blist> <blist> <bibtext> Gordon MJ. Cutting the Gordian knot: A two-part approach to the evaluation and professional development of residents. Academic Medicine. 1997; 72; 10: 876-880</bibtext> </blist> <blist> <bibtext> Govaerts MJB, van der Vleuten CPM, Holmboe ES. Managing tensions in assessment: Moving beyond either-or thinking. Medical Education. 2018; 85; 2: 212-220</bibtext> </blist> <blist> <bibtext> Harris P, Bhanji F, Topps M, Ross S, Lieberman S, Frank JR. Evolving concepts of assessment in a competency-based world. Medical Teacher. 2017; 39; 6: 603-608</bibtext> </blist> <blist> <bibtext> Harrison CJ, Könings KD, Dannefer EF, Schuwirth LWT, Wass V, van der Vleuten CPM. Factors influencing students' receptivity to formative feedback emerging from different assessment cultures. Perspectives on Medical Education. 2016; 5; 5: 276-284</bibtext> </blist> <blist> <bibtext> Hattie J, Timperley H. The power of feedback. Review of Educational Research. 2007; 77; 1: 81-112</bibtext> </blist> <blist> <bibtext> Heritage M. Assessment for learning as support for student self-regulation. Australian Educational Researcher. 2018; 45: 51-63</bibtext> </blist> <blist> <bibtext> LaDonna KA, Hatala R, Lingard L, Voyer S, Watling C. Staging a performance: Learners' perceptions about direct observation during residency. Medical Education. 2017; 51; 5: 498-510</bibtext> </blist> <blist> <bibtext> Lefroy J, Watling C, Teunissen PW, Brand P. Guidelines: The do's, don'ts and don't knows of feedback for clinical education. Perspectives on Medical Education. 2015; 4; 6: 284-299</bibtext> </blist> <blist> <bibtext> Lovell B. What do we know about coaching in medical education? A literature review. Medical Education. 2017; 38; 3: 280-315</bibtext> </blist> <blist> <bibtext> Malhotra S, Hatala R, Courneya C-A. Internal medicine residents' perceptions of the mini-clinical evaluation exercise. Medical Teacher. 2008; 30; 4: 414-419</bibtext> </blist> <blist> <bibtext> Merriam, S. B. (2011). Third update on adult learning theory. In New directions for adult and continuing education. New York: Wiley.</bibtext> </blist> <blist> <bibtext> Miles MB, Huberman AM. Qualitative data analysis. 19942: Thousand Oaks; SAGE</bibtext> </blist> <blist> <bibtext> Moroz A, Horlick M, Mandalaywala N, Stern TD. Faculty feedback that begins with resident self-assessment: Motivation is the key to success. Medical Education. 2017; 50; 2: 210-248</bibtext> </blist> <blist> <bibtext> Nicol DJ, Macfarlane-Dick D. Formative assessment and self-regulated learning: A model and seven principles of good feedback practice. Studies in Higher Education. 2006; 31; 2: 199-218</bibtext> </blist> <blist> <bibtext> Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: A method for assessing clinical skills. Annals of Internal Medicine. 2003; 138; 6: 476-481</bibtext> </blist> <blist> <bibtext> Ramani S, Post SE, Könings K, Mann K, Katz JT, van der Vleuten C. "It's just not the culture": A qualitative study exploring residents perceptions of the impact of institutional culture on feedback. Teaching and Learning in Medicine. 2017; 29; 2: 153-161</bibtext> </blist> <blist> <bibtext> Schut S, Driessen E, van Tartwijk J, van der Vleuten C, Heeneman S. Stakes in the eye of the beholder: An international study of learners' perceptions within programmatic assessment. Medical Education. 2018; 52; 6: 654-663</bibtext> </blist> <blist> <bibtext> Schuwirth LWT, van der Vleuten CPM. Programmatic assessment: From assessment of learning to assessment for learning. Medical Teacher. 2011; 33; 6: 478-485</bibtext> </blist> <blist> <bibtext> Stigt JA, Koele JH, Brand PLP, Jaarsma DAC, Slootweg IA. Workplace mentoring of residents in generic competencies by an independent coach. Perspectives on Medical Education. 2018; 7; 5: 337-341</bibtext> </blist> <blist> <bibtext> Tekian A, Watling CJ, Roberts TE, Steinert Y, Norcini J. Qualitative and quantitative feedback in the context of competency-based education. Medical Teacher. 2017; 39; 12: 1245-1249</bibtext> </blist> <blist> <bibtext> Telio S, Ajjawi R, Regehr G. The "educational alliance" as a framework for reconceptualizing feedback in medical education. Academic Medicine. 2015; 90; 5: 609-614</bibtext> </blist> <blist> <bibtext> Telio S, Regehr G, Ajjawi R. Feedback and the educational alliance: Examining credibility judgements and their consequences. Medical Education. 2016; 50; 9: 933-942</bibtext> </blist> <blist> <bibtext> Turnbull, J, & Van Barneveld, C. (2002). Assessment of clinical performance: In-training evaluation. In International handbook of research in medical education (pp. 793–810). Dordrecht: Springer.</bibtext> </blist> <blist> <bibtext> Urquhart LM, Ker JS, Rees CE. Exploring the influence of context on feedback at medical school: A video-ethnography study. Advances in Health Sciences Education. 2017; 46; 3: 1018-1028</bibtext> </blist> <blist> <bibtext> Voyer S, Cuncic C, Butler DL, MacNeil K, Watling C, Hatala R. Investigating conditions for meaningful feedback in the context of an evidence-based feedback programme. Medical Education. 2016; 50; 9: 943-954</bibtext> </blist> <blist> <bibtext> Watling C. Unfulfilled promise, untapped potential: Feedback at the crossroads. Medical Teacher. 2014; 36; 8: 692-697</bibtext> </blist> <blist> <bibtext> Watling C, Driessen E, van der Vleuten CPM, Lingard L. Learning from clinical work: The roles of learning cues and credibility judgements. Medical Education. 2012; 46; 2: 192-200</bibtext> </blist> <blist> <bibtext> Watling C, Driessen E, van der Vleuten CPM, Lingard L. Learning culture and feedback: An international study of medical athletes and musicians. Medical Education. 2014; 48; 7: 713-723</bibtext> </blist> <blist> <bibtext> Watling C, Ginsburg S. Assessment, feedback and the alchemy of learning. Medical Education. 2019; 53; 1: 76-85</bibtext> </blist> <blist> <bibtext> Watling C, LaDonna KA, Lingard L, Voyer S, Hatala R. "Sometimes the work just needs to be done": Socio-cultural influences on direct observation in medical training. Medical Education. 2016; 50; 10: 1054-1064</bibtext> </blist> <blist> <bibtext> Weinstein DF. Feedback in clinical education: Untying the Gordian Knot. Academic Medicine. 2015; 90; 5: 559-561</bibtext> </blist> <blist> <bibtext> Weller JM, Jolly B, Misur MP, Merry AF, Jones A, Crossley JGM. Mini-clinical evaluation exercise in anaesthesia training. British Journal of Anaesthesia. 2009; 102; 5: 633-641</bibtext> </blist> <blist> <bibtext> Wiliam DWiliam D. Providing feedback that moves learning forward. Embedded formative assessment. 2011: Bloomington; Solution Tree Press: 107-132</bibtext> </blist> <blist> <bibtext> Yin R. Case study research and applications: Design and methods. 2018: Thousand Oaks; SAGE Publications Inc</bibtext> </blist> </ref> <aug> <p>By Kimberley MacNeil; Cary Cuncic; Stéphane Voyer; Deborah Butler and Rose Hatala</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib40" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib34" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib42" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib30" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib41" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib22" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib12" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib19" firstref="ref11"></nolink> <nolink nlid="nl9" bibid="bib20" firstref="ref12"></nolink> <nolink nlid="nl10" bibid="bib27" firstref="ref17"></nolink> <nolink nlid="nl11" bibid="bib28" firstref="ref18"></nolink> <nolink nlid="nl12" bibid="bib47" firstref="ref19"></nolink> <nolink nlid="nl13" bibid="bib35" firstref="ref22"></nolink> <nolink nlid="nl14" bibid="bib36" firstref="ref23"></nolink> <nolink nlid="nl15" bibid="bib43" firstref="ref24"></nolink> <nolink nlid="nl16" bibid="bib13" firstref="ref25"></nolink> <nolink nlid="nl17" bibid="bib17" firstref="ref26"></nolink> <nolink nlid="nl18" bibid="bib32" firstref="ref27"></nolink> <nolink nlid="nl19" bibid="bib18" firstref="ref29"></nolink> <nolink nlid="nl20" bibid="bib31" firstref="ref30"></nolink> <nolink nlid="nl21" bibid="bib39" firstref="ref32"></nolink> <nolink nlid="nl22" bibid="bib23" firstref="ref33"></nolink> <nolink nlid="nl23" bibid="bib33" firstref="ref34"></nolink> <nolink nlid="nl24" bibid="bib25" firstref="ref37"></nolink> <nolink nlid="nl25" bibid="bib48" firstref="ref38"></nolink> <nolink nlid="nl26" bibid="bib10" firstref="ref39"></nolink> <nolink nlid="nl27" bibid="bib29" firstref="ref43"></nolink> <nolink nlid="nl28" bibid="bib37" firstref="ref44"></nolink> <nolink nlid="nl29" bibid="bib26" firstref="ref47"></nolink> <nolink nlid="nl30" bibid="bib38" firstref="ref56"></nolink> <nolink nlid="nl31" bibid="bib16" firstref="ref59"></nolink> <nolink nlid="nl32" bibid="bib44" firstref="ref60"></nolink> <nolink nlid="nl33" bibid="bib24" firstref="ref61"></nolink> <nolink nlid="nl34" bibid="bib46" firstref="ref62"></nolink> <nolink nlid="nl35" bibid="bib11" firstref="ref63"></nolink> <nolink nlid="nl36" bibid="bib14" firstref="ref64"></nolink> <nolink nlid="nl37" bibid="bib21" firstref="ref67"></nolink> <nolink nlid="nl38" bibid="bib15" firstref="ref71"></nolink> <nolink nlid="nl39" bibid="bib45" firstref="ref72"></nolink>
Header DbId: eric
DbLabel: ERIC
An: EJ1259933
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: Necessary but Not Sufficient: Identifying Conditions for Effective Feedback during Internal Medicine Residents' Clinical Education
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22MacNeil%2C+Kimberley%22">MacNeil, Kimberley</searchLink><br /><searchLink fieldCode="AR" term="%22Cuncic%2C+Cary%22">Cuncic, Cary</searchLink><br /><searchLink fieldCode="AR" term="%22Voyer%2C+Stéphane%22">Voyer, Stéphane</searchLink><br /><searchLink fieldCode="AR" term="%22Butler%2C+Deborah%22">Butler, Deborah</searchLink><br /><searchLink fieldCode="AR" term="%22Hatala%2C+Rose%22">Hatala, Rose</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-0521-2590">0000-0003-0521-2590</externalLink>)
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Advances+in+Health+Sciences+Education%22"><i>Advances in Health Sciences Education</i></searchLink>. Aug 2020 25(3):641-654.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 14
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2020
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22College+Faculty%22">College Faculty</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Schools%22">Medical Schools</searchLink><br /><searchLink fieldCode="DE" term="%22Graduate+Students%22">Graduate Students</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Feedback+%28Response%29%22">Feedback (Response)</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Teacher+Attitudes%22">Teacher Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Teacher+Student+Relationship%22">Teacher Student Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Observation%22">Observation</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink><br /><searchLink fieldCode="DE" term="%22Coaching+%28Performance%29%22">Coaching (Performance)</searchLink><br /><searchLink fieldCode="DE" term="%22Formative+Evaluation%22">Formative Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Internal+Medicine%22">Internal Medicine</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10459-019-09948-8
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1382-4996
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents' and 7 faculty members' perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2020
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1259933
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1259933
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1007/s10459-019-09948-8
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 14
        StartPage: 641
    Subjects:
      – SubjectFull: College Faculty
        Type: general
      – SubjectFull: Medical Schools
        Type: general
      – SubjectFull: Graduate Students
        Type: general
      – SubjectFull: Medical Students
        Type: general
      – SubjectFull: Feedback (Response)
        Type: general
      – SubjectFull: Student Attitudes
        Type: general
      – SubjectFull: Teacher Attitudes
        Type: general
      – SubjectFull: Teacher Student Relationship
        Type: general
      – SubjectFull: Observation
        Type: general
      – SubjectFull: Barriers
        Type: general
      – SubjectFull: Coaching (Performance)
        Type: general
      – SubjectFull: Formative Evaluation
        Type: general
      – SubjectFull: Internal Medicine
        Type: general
    Titles:
      – TitleFull: Necessary but Not Sufficient: Identifying Conditions for Effective Feedback during Internal Medicine Residents' Clinical Education
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: MacNeil, Kimberley
      – PersonEntity:
          Name:
            NameFull: Cuncic, Cary
      – PersonEntity:
          Name:
            NameFull: Voyer, Stéphane
      – PersonEntity:
          Name:
            NameFull: Butler, Deborah
      – PersonEntity:
          Name:
            NameFull: Hatala, Rose
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 08
              Type: published
              Y: 2020
          Identifiers:
            – Type: issn-print
              Value: 1382-4996
          Numbering:
            – Type: volume
              Value: 25
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Advances in Health Sciences Education
              Type: main
ResultId 1