May 2019

posted in: 2019 Journal Clubs | 0

Student perspectives on feedback

The Art (and Artifice) of Seeking Feedback:  Clerkship Students’ Approaches to Asking for Feedback.  Bing-You R, Hayes V, Palka T, Ford M, Trowbridge R.

Academic Medicine. 2018;93;1218–1226.

Reviewed by Srividya Naganathan



What was the study question?

What are the factors and behaviors associated with students seeking feedback?

How was the study done?

Third year clerkship students from both traditional block rotations as well as longitudinal integrated clerkship (LIC) were invited to participate in a semi-structured interview process. Transcripts were coded and themes identified using the constant comparative method.  The following questions were asked:

  1. Why do you seek information about your performance of a clinical task?
  2. Which factors influence the way you seek feedback?
  3. How do you obtain information about your performance?
  4. How does your relationship with faculty influence the way you seek feedback?


What were the results?

A total of 14 students, 6 from block rotations and 8 from LIC participated in the study.

  • Students sought feedback as a means to improve skills and knowledge but also to appear engaged.  Avoiding feedback was due to reluctance to receive negative feedback.
  • Factors influencing the way feedback was sought included the clinical setting (busy practice with less opportunities), time availability and resident/faculty cues (signals encouraging feedback).
  • Students obtained feedback by both inquiry and indirect/non-inquiry methods. Most students felt summative feedback was unhelpful and wanted training on how to seek feedback.
  • Students were more likely to seek feedback from faculty perceived to be approachable, supporting and having a mutually trusting relationship. Interestingly, the students identified that residents/faculty who were lenient or too nice were unlikely to give effective feedback.
  • Students in the LIC had more interaction with the faculty which facilitated seeking feedback.

What are the implications of these findings?

Although, the study has a small sample size, it is a snapshot of students’ perceptions and behaviors influencing feedback seeking.  Student motivation, perceived benefits and risks, availability of time and student-faculty relationship are all factors that influence feedback seeking. It may be time to train the students on seeking feedback and place the onus on them!

Editor’s Note:  The authors start with the proposition that feedback involves dialogue rather than just information transfer.  The student perspective is a crucial part of that dialogue.  I especially appreciate the feedback training module for students provided in the appendix of the article.  A few hours of training, if effective, may be one of the best investments a medical school can make. (JG)



Positive reinforcement—it works with faculty members, too.

The Exceptional Teacher Initiative:  Finding a Silver Lining in Addressing Medical Student Mistreatment.

Blackall, GF, Wolpaw, T, & Shapiro, D. Academic Medicine: March 12, 2019 – Publish Ahead of Print

Reviewed by: Joanna Holland

What was the problem?

After Penn State College of Medicine implemented systems to deal with increasing reports of learner mistreatment, their faculty expressed concern that a culture focusing on negative behaviors was being created, and that outstanding teaching was not being acknowledged. This paper describes the Exceptional Teacher Initiative, which was developed and implemented with the goal of rebalancing the approach to mistreatment.

What was done?

The University used a conceptual framework from behavior modification: “Catch them doing something right” in order to strengthen desired behaviors. Students were sent an e-mail requesting submissions about exceptional teachers “who have impacted or influenced you in a significant way...” Students could identify themselves or remain anonymous, and comments would be passed on to the teachers and their educational and clinical heads, and potentially posted on the College of Medicine website. A prompt for submissions was also placed in all course and clerkship evaluations, immediately before the Graduate Questionnaire (GQ) mistreatment questions. The online submission form asked students to “Please tell us your story of how this teacher challenged you and extended your knowledge in a respectful way.”

What were the results?

After 12 months, 553 narratives naming 253 individuals across 37 departments had been submitted by learners. Subsequently a monthly feature was introduced in which each month one of the named educators is featured on a poster displayed prominently and incorporated in a monthly newsletter. Both faculty and students expressed appreciation for the effort to highlight positive examples of teaching; the article includes illustrative examples of both student narratives and faculty responses. The GQ results for students reporting mistreatment also decreased from 46.4% to 36.6% the year following implementation of this initiative.

What are the implications?

Approaches that focus only on responding to negative behaviors of faculty may “cast a cloud over the institution and teaching”. Inclusion of a focus on faculty members who can serve as positive role models may contribute to improving a respectful learning environment. These narratives also have the potential to spread innovative teaching techniques as they are shared widely.

Editor’s Comments: These authors describe a simple initiative to change the lens of the learning environment from only focusing on the “bad” with respect to learner mistreatment, to acknowledging the amazing work that so many people do for learners every day, providing a more balanced approach. Despite impressive reduction in reports of mistreatment on the GQ, the rate of 36.6% after the intervention clearly indicates we have much more room to go to eliminate mistreatment (KFo).



The Role of Home Visits For Special Needs Children in Meeting Clerkship Competencies


Operation Homefront: Meeting Clerkship Competencies with Home Visits to Families of Children with Special Needs.

Anderson E, Boyd B, Qureshi N, Stirling J, McCarthy V, Kuczewski M

Academic Pediatrics 2019; 19(2): 170-176

Reviewed by Chas Hannum

What was the study question?

How, and to what extent, does participation in a home visit experience with families of children with special needs meet pediatric clerkship competencies?

How was the study done?

During a single academic year at a single institution, pediatric clerkship students took part in a visit to the home of a child with special needs.  Groups of 3-4 students met with a family twice during their clerkship, which typically included a home visit and a family outing/medical appointment. At the end of the clerkship, students completed written reflections about their experiences. COMSEP competencies that the research team expected to be addressed by the home visit and supported through reflective writing were identified, and de-identified student reflections were qualitatively analyzed by a systematic, structured conventional content approach and compared to these competencies.

What were the results?

There were a total of 152 reflections, and 100% discussed at least one of the expected competencies. The average number of competencies discussed was roughly three, with over 30% of students highlighting four or more competencies. The two most common competencies mentioned were “demonstration of respect for patient, parent, and family attitudes, behaviors, and lifestyles” and “demonstration of positive attitude and regard for education” (90% and 76% of reflections, respectively). The other competency themes included communication, advocacy, patient education, barriers to care, and professionalism.

What are the implications of these findings?

The authors note that a community-based, parent-directed experience can help meet COMSEP competencies and promote a better understanding of patient-centered care for pediatric clerkship students. Limitations of this study include a defined competency analysis and the inability to know how this experience impacts future practice habits. Home visit programs and written reflection may be a unique way to augment the clinical learning environment for pediatric clerkship students.

Editor’s note: COMSEP competencies aside, this sounds like a terrific program both to familiarize students with the care of special needs children as well as giving the students an opportunity to participate in a home visit. Both of those aspects of this program, labeled Operation Homefront, might, if time and energy allow, enhance any medical students pediatric learning experience. (RR)




What Shapes our Master Clinicians?

An Inquiry Into the Early Careers of Master Clinicians.

Murthy, Vivek K., et al. Journal of Graduate Medical Education 2018; 10(5):500-506.

Reviewed by Adam Cohen

What was the study question?

What early career clinical experiences and learning behaviors helped shape the expertise of peer-defined master academic clinicians?

How was the study done?

This study was a retrospective qualitative interview study, with the study team conducting individual semi-structured interviews with 17 members of UCSF’s Department of Medicine Council of Master Clinicians who volunteered to be part of the study. Interviews were recorded and transcribed prior to using a general inductive approach for thematic analysis, which included descriptive coding, recognition of themes and patterns, and refining of themes into major findings.

What were the results?

The study found four overlapping themes of the early habits of master clinicians included: (1) Consistent learning efforts such as reading, teaching and tracking outcomes, (2) rigorous skill development focused on communication, physical exam, and clinical reasoning, (3) cultivating habits of mind including humanism, joy in work, humility, and rigor in analysis, and (4) a clinically rich environment including high volume, peer learning and practicing outside their comfort zone. The authors concluded by correlating these themes with habits during later careers to suggest that expert physicians adopt these behaviors early and maintain them throughout their career. Finally, the authors suggested strategies and action items for early career physicians based on the study findings.

What are the implications of these findings?

This article contributes to the ongoing study of clinical mastery and is the first of its kind to focus specifically on early career habits. Creating a culture and education system which encourages these habits may be a way to enhance the clinical skills of early career physicians.

Editor’s note: Although this study focuses on faculty physicians, the relevance to trainees is obvious. The habits described are the ones to which trainees can and should aspire. Role modeling is a crucial part of medical education and this study demonstrates the specific practices and behaviors trainees would be well served by imitating. (RR)