Feedback in family medicine clerkships: a qualitative interview study of stakeholders in community-based teaching

Figures & data

Table 1. Inclusion and exclusion criteria

Group	Inclusion criteria	Exclusion criteria
1 (Students)	family medicine clerkship completed at the medical faculty of Tübingen University (sixth study year)	family medicine clerkship not yet completed (study years 1–5) family medicine clerkship not completed at the medical faculty of Tübingen University
2 (GP Trainers)	GP physicians associated with and accredited by Tübingen University Prior supervision of medical students in the family medicine clerkship or the Practical year (PJ) in family medicine	Had not yet supervised students in the family medicine clerkship or the Practical year (PJ) in family medicine, former teacher/mentor to the interviewer, other relationship that might cause a bias
3 (Faculty)	Member of a German medical faculty in family medicine involved in the organisation of the family medicine clerkship	Supervisor of the present study, Another member of the same university already took part in the study, Interview partner is not involved in the organisation of the family medicine clerkship

Table 2. Participant demographics

Group	1 (Students)(n = 15)	2 (GPs)(n = 13)	3 (Faculty)(n = 12)
Age (Median; Min-Max)	26 (23–32)	60.5 (38–68)	50 (33–62)
Missing (n% total)	0 (0%)	1 (7.7%)	1 (8.3%)
Female (n% total)	12 (80%)	4 (30.8%)	6 (50%)

Table 3. Excerpt of the coding frame, main category ‘feedback’

CATEGORY	SUBCATEGORY		CITATION
Content	technique (e.g., observed procedures)		‘And then to hear from someone with experience: “Okay, […] the suspected diagnoses you thought of were right, but we’ll start by checking this and that.” So I think this kind of case discussion I find most helpful because that just helps me find the right thread.’ (ST-1, 41)
	medical issues		I: “Did you receive helpful feedback from your teaching GP?“ ST: “Yes, […] especially on how to interact with the patients, because I didn’t really know how to deal with them. Am I allowed to be frank and direct, or do I have to hold back[…] And they always told me: ‘No, you did it all well, it’s okay like that.’ That was great.“(ST-7, 21) GP: “and I mean feedback goes both ways … I once … I once, how should I put this now … actually treated a patient unmedically because he was very difficult, and the student pointed it out to me by asking, questioning what I was doing now and then I realised, ‘Actually, he’s right!’“ (GP-2, 68)
	behaviour, appearance, attitudes		General Practitioner (GP): „[…] And one day I asked him: ‘Listen! Why did you actually choose to study medicine?’ And then he said his marks had been good enough and a doctor had a good reputation and would earn money. And then I told him: ‘Boy, […] that’s not enough for this job as you will experience so many things where reputation and money are not enough. And the reputation, you don’t get it with the title, you have to earn it. I: “How did he react?” GP:’ Nicely! […] He thought about it and then the next day he came and asked […]:’How did you mean that?’ And then I told him certain things.” (GP-711-13 and 113–114) ‘I: Do you give your students feedback regarding their behaviour? B: I always do that … […] that’s very important, that someone gets feedback, whether he now seems too timid, or anxious, or in a certain situation perhaps would have had other options.’ (GP-5, 32)
	didactics and method		I:” […] did you give feedback to your teaching physician […]? ST: Yes. So when I was allowed to do something, like taking a blood sample from the jugular. I already told him that I thought it was good that I was allowed to do that because otherwise you never have the opportunity. Or that you are only allowed to do that after watching once. I also thanked him, for example, when I was allowed to be present during medication-assisted treatment or was allowed to interview patients.” (ST-7, 27)” GP: „But at the end of the clerkship, I always ask if there is something that should be changed fundamentally, or what they were missing […] Unfortunately, so far, they did not mention anything they were missing, so I don’t know if they like it or not. (GP 11, 60–61)
Frame	Situation	Fb talk at the end of the clerkship	ST: ‘So at the end of the clerkship, he [The GP teacher] showed me how he filled out the evaluation form, and consequently I guess he was satisfied.’ (ST-11, 28)”
		Fix timeslots for fb during the clerkship	‘Every day between 10 and half past 10 […] every morning there is a conversation if we have time for it. [.] If there is still something to discuss from the previous day, whatever comes to mind.’ (GP-12, 39)
		Fb during consultations	ST: „He presumed a lot of knowledge. Because I could not remember everything at once, there were comments that stated that I should know this … this sometimes happened while a patient was present.” I: ”Ok, and how did that feel?“ ST:‘Well, not that great.’ (ST-2, 29–30)
		Fb talk in a special setting outside the practice	GP: ‘Typically, I invite [students] I’ve grown fond of on the last evening of the clerkship. There is a nice restaurant nearby, and we go there for dinner, and I tell a little about what has moved me [during the clerkship], what was special or especially different … what was good and what was not that good.’ (GP-5, 36)
	Initiation	GP initiates feedback	GP: ‘And what I additionally do is: I ask them after the first half of the time, well they start on Tuesday[.] and on Friday they get the task against the background of what they have already experienced to think about: What is still missing? What do I have to do in the following week?’(GP-7, 61)
		Student is seeking feedback	ST: „And then in the end, I explicitly asked [my teaching GP] … I don’t know if otherwise that would have come from her part. I asked her if she had any tips for me, what I should improve, or revise or do […]”(ST-4, 25)
		Spontaneously given feedback	ST: ”After every patient [encounter], he closed the door and briefly discussed the case with me and told me what I could have done differently. “ (ST-15, 31)
Indirect feedback	Nonverbal feedback		ST: „Sometimes [the GP] glanced at me questioningly when I wasn’t able to do something because I only knew it in theory or probably had forgotten a lot of things.” (ST-2, 23)
	Self-reflection, feedback through (success) experiences		ST: My most positive experience [during the clerkship] was that I made a diagnosis correctly, which actually was not too easy. It was about atypical pneumonia. I thought by myself: This sounds strange down there to the right[…] … and as the patient came back with the X-ray, there was really something to see on the imaging, and I was really proud of myself.” (ST-3, 40) GP: ‘Occasionally I do tell [the students] if they do something good, I do give feedback, and I think they notice it as well as they are allowed to do more things and work more and more independently. (GP-10, 26–27)’
Problems	Feedback does not take place	lack of opportunity/initiation	I: ‘Did you get useful feedback from your teaching GP?’ ST: „Not too much … . Actually, this didn’t really happen […] the script for the clerkship says that a feedback talk should take place … we didn’t really do that … actually we did not do it at all.” (ST-1, 26) I: “Did a student ever give you feedback on your work as doctor and as teacher? GP: ‘Well, that’s what I’m actually missing a bit. I get feedback if I ask for it, if I ask the students in the end: What was good, what was bad? What would you say was great? The students usually give very little [feedback], and I’d wish for more. Even negative aspects: “I’ve noticed you do this that way and at university we learned it differently. Why do you do it like that?” I’d like to get more feedback and would be happy to receive it.’ (GP-12, 41)
		(Not) daring to give feedback	ST:”I didn’t pass criticism on him, no […] I don’t know if it would have been understandable for him, because […] it’s a lot of subjective feeling, as well. (ST-2, 33) GP: ‘[…] one feels that the students are not frank [with the teaching GP]. I think they are just afraid to say something wrong. Even though you stress that they can’t say anything wrong … . I think as a student, you just don’t say it.’(GP-11, 59)
		Unawareness	ST: I have to admit at that point in time I wasn’t really aware of it. […] Before, I had not experienced [that it could be different], and I could not say that it was bad. […]” (ST-6, 56) GP: No, I didn’t report [the problematic behaviour of the student [to the faculty], as it was one of my first, or the first student, and I was rather surprised how little she took the clerkship seriously. Only over time, I had the comparison, how conscientiously all the others dealt with the clerkship.” (GP-10, 38)
		little basis for feedback	ST: ‘Well, I would not have known what I should have been given feedback for […] of course I would have liked to receive more [feedback] but that would have implied that I could have done more on my own.’ (ST-6, 44–45)
ASSESSMENT AND EVALUATION	Student grading	Student assessment sheet	F: ‘For one thing, on the evaluation sheet that’s in our accompanying booklet, the teaching physicians can add a comment at the bottom. “Very involved, very interested, disinterested, shouldn’t be in general practice, would be better off in research, can’t hold conversations … ” that, of course, is reflected in the grading.’ (F-10, 51)
		Case report	F: „That means I’m relying on what the students write to me on my request. Of course, I prompt them to give written feedback, but I probably get five feedback reports in one semester with 160 students. Most of them are formulated very generally, like: „Was great!” or something like that. And probably one feedback per semester, by rule of thumb one feedback per semester contains specific feedback.” (F-9, 19–20)
	Information forwarding		F: ‘A teaching practice doesn’t get the evaluation of one student directly. Only if the teaching practice had more than five students for the clerkship, the evaluations of this group are handed down directly to the teaching practice. […]That’s how the rules are.[…] We are regularly informed by the teaching practices, that this is not effective, because they either get no direct feedback at all …, of course, they get information of the department on how the clerkship went in general […]but no [direct feedback] for the respective practices. They don’t like that, but we do not currently have another solution.’ (F-8, 24–27) ‘I: In what way do you receive feedback from the institute for your teaching activities […]? B: We don’t really receive any feedback. I don’t know. At least specific. Sometimes you find out something on a “GP day” [CME for GPs at campus]. There used to be an evaluation of the students’ evaluation forms. But that was then always general, […] and about one semester, so nothing specific.’ (GP-1,63)

Figure 1. Communication pathways in community-based family medicine clerkships; 1: On – site between teacher and learner; 2: between learner and faculty (e.g., case reports); 3: between community-based teacher and university (e.g., student assessment sheet).

Table

Four main reasons contribute to the lack of feedback in community-based teaching: Lack of initiation and opportunities, not daring to give feedback, unawareness (of correct feedback and/or previous experiences with feedback), and little basis for feedback. In community-based teaching environments, feedback between students and GP trainers is supplemented by two additional yet unused communication pathways that involve university faculty as feedback facilitators Universities are therefore in a unique position to facilitate the implementation of effective feedback in community-based learning environments Both instructors and learners should be prepared to give and receive effective feedback, and university faculty should be aware of their role as feedback facilitators