Residents provide feedback to their clinical teachers: Reflection through dialogue

Figures & data

Table

Practice points

EFFECT-S, a carefully designed system in which residents provide formative feedback to their clinical supervisors, is highly acceptable to supervisors and residents. Residents are able to facilitate reflective feedback processes by helping supervisors to understand differences between external feedback and self-perceptions, by interpreting feedback content, identifying learning and performance needs. Important conditions for successful implementation include creating a safe environment for both residents and supervisors and honest feedback provided by residents, but creating safety for supervisors and residents require different actions. EFFECT-S offers the opportunity for residents to practice their feedback skills, which is part of the CanMEDS competencies and ACGME core competencies. It is a first step to peer feedback and a useful outcome for residents when they supervise clerks. A carefully planned evaluation can improve the learning climate and soften hierarchical relations at a department without undermining the authority of clinical teachers.

Table 1  Design principles and characteristics for providing clinical teachers with formative upward feedback, applied in the EFFECT-S

Principle	Characteristics	Consequences for the design of EFFECT-S
A carefully designed evaluation system, based on a quality assessment instrument	The system contains following steps: assessing the performance, providing feedback, reflection and decision making. The instrument needs to cover all important aspects of clinical teaching, to be adequately informative for formative evaluation, and meet general demands of validity and reliability	• A four-step system was developed: 1. Introduction and agreements at department (see also acceptability) 2. Filling in questionnaires (both resident and supervisor) 3. Providing feedback report 4. Dialogue for further reflection and decision-making
		• The EFFECT questionnaire is used, a validated instrument, based on learning theory (Fluit 2012)
Useful feedback	For feedback to be useful for learning it needs to be honest, informative, recognizable, understandable, and it should invite reflection and decision making. For upward feedback, a safe environment is needed both for recipient and provider	• The evaluation is anonymous for residents for creating honesty and safety • Supervisors fill in a self evaluation • Written feedback report includes individual and group scores, self evaluation and written comments • A face to face meeting (dialogue) for stimulating further understanding, reflection and decision making • Dialogue is guided by a moderator for creating safety for both residents and supervisor • Residents are trained to provide feedback
Creation of acceptability	The effectiveness of feedback depends on the acceptance by clinical teachers and supervisors as well as residents Understanding the purpose and agreement are crucial. Evaluation needs to be just in time and procedures need to be tailor-made	• EFFECT-S is carefully introduced an discussed with head of department, staff and residents, so expectations are clear • Procedures can be made tailor-made • Participation in EFFECT-S is voluntary for departments, the department chooses when to start

Table 2  Codes and themes used for analyzing the interviews

CODE (number of subcodes)	Description of main content of the quotations	Frequency
DIALOGUE (11)	face-to-face feedback interview of the EFFECT system	336
EVALUATION (8)	evaluation of supervisors in general, not only this particular evaluation	235
PROCEDURE (7)	this particular evaluation of supervisors with EFFECT	183
QUESTIONNAIRE (7)	the questionnaire, both its content and its use	107
FEEDBACK (5)	providing or receiving feedback, either written or oral, and the acceptance and recognition of this feedback	81
SELF-EVALUATION (2)	filling in the questionnaire by the supervisors themselves	44
THEMES (related to the effectiveness of the design, the EFFECT-S)
Awareness: thinking about clinical teaching, reflection and/or discussion with others		40
Climate: the working and/or learning climate at the department or more in general		37
Relations: relations between residents and supervisors or among residents or supervisors themselves and other than hierarchy		27
Safety: creating/experiencing a safe environment for evaluating supervisors		26
Honesty: residents or supervisors being honest during the evaluation		25
Hierarchy: the hierarchical relations between residents and supervisors		10

Table 3  Conditions for adequate use of the different elements of EFFECT-S

Safety
For residents promoted by	For supervisors promoted by
• anonymous evaluation • the dialogue by two residents who represent the group of residents • a moderator with expertise in guiding feedback sessions	• not anonymous evaluation • clear goals of the evaluation • good timing of the evaluation • residents instructed how to rate supervisors • honest residents • dialogue by residents who know you • residents who are well prepared and capable of explaining the results • a moderator for guiding the dialogue
For residents impaired by	For supervisors impaired by
• feedback report containing offensive comments	• anonymous evaluations • too close relation with a resident
Honesty of residents
For residents promoted by	For supervisors promoted by
• feedback report interpreted with moderator and/or training of residents • written feedback report available (forces them to discuss strong/weak points) • dialogue with supervisor you know to provide examples • supervisor willing to change • evaluation taken seriously by supervisor	• moderator with expertise in guiding feedback sessions • dialogue with resident you know to provide examples
For residents impaired by	For supervisors impaired by
• too close relation with the supervisor • hierarchical relations	–

Table 4  Effects of EFFECT-S for residents and supervisors

	Residents	Supervisors
Awareness (in relation to clinical teaching)	They learned: • different aspects of clinical teaching • complexity of clinical teaching • supervisors are more open to feedback than expected • how to provide feedback • communication skills • resident influence on supervisor performance • the importance of taking an active role in one's own learning process • there are more ways of being a good doctor	They learned: • different aspects of clinical teaching • the strong and weak points in their own teaching • residents provide good feedback • what residents need for their learning process • importance of explicit exchange of thoughts with residents • need for sharing teaching values with residents • what is a good doctor
Climate	• more open climate • improved collaboration • more open learning climate	• the first step towards change has been taken
Relations	• improved relations with supervisors • get to know that supervisor	• good, open, and honest relations during dialogue
Hierarchy	• reduced distance between supervisors and residents	• closer to each other despite hierarchical relations

Figure 1. The EFFECT system (EFFECT-S).

Fluit CR, Bolhuis S, Grol R, Ham M, Feskens R, Laan R, Wensing M. Evaluation and feedback for effective clinical teaching in postgraduate medical education: Validation of an assessment instrument incorporating the CanMEDS roles. Med Teach 2012; 34(11)893–901

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