Joan Sargeant

Giving feedback in clinical settings

Think about a clinical teaching session that you supervised recently. How much feedback did you provide? How useful do you think your feedback was?

Reflection: a link between receiving and using assessment feedback.

Problem statement and background Feedback is essential to learning and practice improvement, yet challenging both to provide and receive. The purpose of this paper was to explore reflective processes which physicians described as they considered their assessment feedback and the perceived utility of that reflective process. Methods This is a qualitative study using principles of grounded theory. We conducted interviews with 28 family physicians participating in a multi-source feedback program and receiving scores across the spectrum from high to low. Results Feedback, especially negative feedback, evoked reflective responses. Reflection seemed to be the process through which feedback was or was not assimilated and appeared integral to decisions to accept and use the feedback. Facilitated reflection upon feedback was viewed as a positive influence for assimilation and acceptance. Conclusions Receiving feedback inconsistent with self-perceptions stimulated physicians’ reflective processes. The process of reflection appeared instrumental to feedback acceptance and use, suggesting that reflection may be an important educational focus in the formative assessment and feedback process.

Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes

Self-appraisal has repeatedly been shown to be inadequate as a mechanism for performance improvement. This has placed greater emphasis on understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one’s self-perceptions it is important to understand how learners interpret, accept, and use feedback (or not) and the factors that influence those interpretations. 134 participants from 8 health professional training/continuing competence programs were recruited to participate in focus groups. Analyses were designed to (a) elicit understandings of the processes used by learners and physicians to interpret, accept and use (or not) data to inform their perceptions of their clinical performance, and (b) further understand the factors (internal and external) believed to influence interpretation of feedback. Multiple influences appear to impact upon the interpretation and uptake of feedback. These include confidence, experience, and fear of not appearing knowledgeable. Importantly, however, each could have a paradoxical effect of both increasing and decreasing receptivity. Less prevalent but nonetheless important themes suggested mechanisms through which cognitive reasoning processes might impede growth from formative feedback. Many studies have examined the effectiveness of feedback through variable interventions focused on feedback delivery. This study suggests that it is equally important to consider feedback from the perspective of how it is received. The interplay observed between fear, confidence, and reasoning processes reinforces the notion that there is no simple recipe for the delivery of effective feedback. These factors should be taken into account when trying to understand (a) why self-appraisal can be flawed, (b) why appropriate external feedback is vital (yet can be ineffective), and (c) why we may need to disentangle the goals of performance improvement from the goals of improving self-assessment.

The processes and dimensions of informed self-assessment: a conceptual model.

Purpose To determine how learners and physicians engaged in various structured interventions to inform self-assessment, how they perceived and used self-assessment in clinical learning and practice, and the components and processes comprising informed self-assessment and factors that influence these. Method This was a qualitative study guided by principles of grounded theory. Using purposive sampling, eight programs were selected in Canada, the United States, the United Kingdom, the Netherlands, and Belgium, representing low, medium, and high degrees of structure/rigor in self-assessment activities. In 2008, 17 focus groups were conducted with 134 participants (53 undergraduate learners, 32 postgraduate learners, 49 physicians). Focus-group transcripts were analyzed interactively and iteratively by the research team to identify themes and compare and confirm findings. Results Informed self-assessment appeared as a flexible, dynamic process of accessing, interpreting, and responding to varied external and internal data. It was characterized by multiple tensions arising from complex interactions among competing internal and external data and multiple influencing conditions. The complex process was evident across the continuum of medical education and practice. A conceptual model of informed self-assessment emerged. Conclusions Central challenges to informing self-assessment are the dynamic interrelationships and underlying tensions among the components comprising self-assessment. Realizing this increases understanding of why self-assessment accuracy seems frequently unreliable. Findings suggest the need for attention to the varied influencing conditions and inherent tensions to progress in understanding self-assessment, how it is informed, and its role in self-directed learning and professional self-regulation. Informed self-assessment is a multidimensional, complex construct requiring further research.

Theories to aid understanding and implementation of interprofessional education.

Multiple events are calling for greater interprofessional collaboration and communication, including initiatives aimed at enhancing patient safety and preventing medical errors. Education is 1 way to increase collaboration and communication, and is an explicit goal of interprofessional education (IPE). Yet health professionals to date are largely educated in isolation. IPE differs from most traditional continuing education in that knowledge is largely socially created through interactions with others and involves unique collaborative skills and attitudes. It requires thinking differently about what constitutes teaching and learning. The article draws upon a small number of social and learning theories to explain the rationale for IPE needing a new way of thinking, and proposes approaches to guide development and implementation of IP continuing education. Social psychology and complexity theory explain the influence of the dynamism and interaction of internal (cognitive) and external (environmental) factors upon learning and set the stage for IPE. Theories related to professionalism and stereotyping, communities of practice, reflective learning, and transformative learning appear central to IPE and guide specific educational interventions. In sum, IPE requires CE to adopt new content, recognize new knowledge, and use new approaches for learning; we are now in a different place.

Challenges in multisource feedback: intended and unintended outcomes

Context  Multisource feedback (MSF) is a type of formative assessment intended to guide learning and performance change. However, in earlier research, some doctors questioned its validity and did not use it for improvement, raising questions about its consequential validity (i.e. its ability to produce intended outcomes related to learning and change). The purpose of this qualitative study was to increase understanding of the consequential validity of MSF by exploring how doctors used their feedback and the conditions influencing this use.

Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict.

Purpose Informed self-assessment describes the set of processes through which individuals use external and internal data to generate an appraisal of their own abilities. The purpose of this project was to explore the tensions described by learners and professionals when informing their self-assessments of clinical performance. Method This 2008 qualitative study was guided by principles of grounded theory. Eight programs in five countries across undergraduate, postgraduate, and continuing medical education were purposively sampled. Seventeen focus groups were held (134 participants). Detailed analyses were conducted iteratively to understand themes and relationships. Results Participants experienced multiple tensions in informed self-assessment. Three categories of tensions emerged: within people (e.g., wanting feedback, yet fearing disconfirming feedback), between people (e.g., providing genuine feedback yet wanting to preserve relationships), and in the learning/practice environment (e.g., engaging in authentic self-assessment activities versus “playing the evaluation game”). Tensions were ongoing, contextual, and dynamic; they prevailed across participant groups, infusing all components of informed self-assessment. They also were present in varied contexts and at all levels of learners and practicing physicians. Conclusions Multiple tensions, requiring ongoing negotiation and renegotiation, are inherent in informed self-assessment. Tensions are both intraindividual and interindividual and they are culturally situated, reflecting both professional and institutional influences. Social learning theories (social cognitive theory) and sociocultural theories of learning (situated learning and communities of practice) may inform our understanding and interpretation of the study findings. The findings suggest that educational interventions should be directed at individual, collective, and institutional cultural levels. Implications for practice are presented.

Features of assessment learners use to make informed self-assessments of clinical performance.

Medical Education 2011: 45: 636–647

Videoconferencing for Practice-Based Small-Group Continuing Medical Education: Feasibility, Acceptability, Effectiveness, and Cost.

Introduction: Small‐group, practice‐based learning is an effective and well‐accepted method of continuing medical education (CME). However, one limitation is that many physicians work in communities with fewer than the minimum number recommended for an effective learning group. Videoconferencing has the potential to remove this limitation. The purpose of this study was to evaluate the feasibility, acceptability, effectiveness, and cost of conducting practice‐based, small‐group CME learning by videoconference. Methods: Through a videoconferencing link, 10 learners in three communities were guided through four practice‐based learning modules by a trained facilitator at a fourth site. Data were collected through evaluation questionnaires, direct observation by the research team, pre‐ and post‐knowledge tests, a focus group, and an interview. Results: A total of 31 learners participated in the four modules. Videoconferencing was generally well accepted by learners. The facilitator and research team observers noted that muting microphones, video quality, audio quality, and audio lag all somewhat hindered discussion. Overall, the facilitator found moderating by videoconference only slightly more difficult than a face‐to‐face session. There was evidence of knowledge gain, with post‐test scores being 20% higher than pretest scores (p = .006). Learners reported nine practice changes from taking the modules. At commercial rates, telecommunications costs per videoconferenced module were approximately CAN

Evaluation of learning outcomes in Web-based continuing medical education.

1,200. Discussion: Videoconferencing has the potential to bring the benefits of small‐group, practice‐based learning to many physicians; however, strict attention to videoconferencing techniques is required. Cost is also an important consideration.