Risky business: medical students’ feedback-seeking behaviours: a mixed methods study

Figures & data

Figure 1. A model of medical student feedback-seeking behaviour, modified from Teunissen and colleagues’ model of trainee feedback-seeking behaviour [4]. Arrows indicate hypothesised relationships between predictors, mediators, and outcomes, as follows: hypothesis (H) 1a: feedback benefits are positively associated with feedback monitoring. H1b: feedback benefits are positively associated with feedback inquiry. H2a: feedback costs are negatively associated with feedback monitoring. H2b: feedback costs are negatively associate with feedback inquiry. H3: feedback costs and benefits are negatively associated. H4: learning goal orientation is positively associated with feedback benefits. H5: learning goal orientation is negatively associated with feedback costs. H6: performance goal orientation is positively associated with feedback costs. H7: instrumental supervision is positively associated with feedback benefits. H8: supportive supervision is negatively associated with feedback costs. H9: a positive relationship exists between a more supportive leadership style and perceived feedback benefits.

Figure 2. Model explaining final-year medical students’ feedback-seeking behaviours. Reported path values are standardized regression weights. Standardized regression weights < 0.20 are significant at the P < 0.05 level; regression weights ≥ 0.20 are significant at the P < 0.001 level. R2 is the percentage of variance explained for that specific variable. To assess different aspects of the overall model fit, we used several indices including the chi-square index divided by degrees of freedom, which should be less than 3 for a good model fit. The root mean square error of approximation (RMSEA) should be less than or equal to 0.05 and PCLOSE is the corresponding p value that tests the null hypothesis that the RMSEA is no greater than 0.05. The comparative fit index (CFI) compares the covariance matrix of our empirical model to the observed covariance matrix. A CFI close to 1 indicates a very good fit. The fit indices for this model were: chi-square/df = 1.6, RMSEA = 0.043, PCLOSE = 0.54, and CFI = 0.99. The CFI indicates that 99% of the covariance in the data is accounted for by this model. The resulting model explains 2% of the variance on the perceived feedback costs variable, 32% of the variance on perceived feedback benefits, 17% of the variance on feedback monitoring, and 23% of the variance on feedback inquiry.

Figure 3. Diagram of the process used to integrate the data from the mixed methods in this study exploring feedback-seeking behaviours in undergraduate medical students at three transcontinental campuses. FB = feedback. FSB = feedback-seeking behaviours.

Table 1. Participant profile for interviews. Fifty-seven students participated, with their details in terms of gender, entry route (direct entry versus graduate entry), site of study included, with total population numbers for each group also indicated.

Average age of participants	25.1 (21–33)
Gender	Male	Female
Participants	26 (46%)	31(54%)
Full Class	269 (52%)	245(48%)
Entry route	Direct Entry	Graduate Entry
Participants	47 (82%)	10 (18%)
Full class	449(87%)	65 (13%)
Site of Study	Dublin	Manama	Kuala Lumpar
Participants	41 (72%)	8 (14%)	8 (14%)
Full Class	323	151	40
Place I Call Home*	Europe	Arab States	U.S. and Canada	South East Asia	Other
Participants	8 (14.0%)	20 (35%)	14(25%)	9 (16%)	6 (11%)
Full class	87(17%)	227 (44%)	100(20%)	69(13%)	31(6%)

Table 2. Means, standard deviations, Cronbach alphas, and correlations among variables in the hypothetical model.

			Correlations
	Mean (SD)	Cronbach alpha	Learning goal	Performance goal	Supportive leadership	Instrumental leadership	Perceived costs	Perceived benefits/value	Feedback monitoring	Feedback inquiry
1. Learning goal	4.82 (0.69)	0.78	1
2. Performance goal	3.73 (0.89)	0.81	0.0076	1
3. Supportive leadership	4.68 (1.06)	0.92	0.1325	0.1188	1
4. Instrumental leadership	4.88 (1.06)	0.92	0.131	0.1202	0.7245	1
5. Perceived costs	4.91 (0.64)	0.73	0.0316	0.0764	−0.0493	−0.0236	1
6. Perceived benefits/value	3.03 (0.62)	0.71	0.2975	0.0887	0.4954	0.4655	−0.1069	1
7. Feedback monitoring	4.62 (0.81)	0.79	0.2471	0.3124	0.0682	0.0595	0.0183	0.2218	1
8. Feedback inquiry	3.63 (1.06)	0.88	0.3148	−0.0329	0.2204	0.2904	0.0131	0.4268	0.0899	1

Table 3. Qualitative themes that describe situational factors relating to feedback-seeking behaviours in medical students.

Theme	Sub-theme	Description	Illustrative quote
Environment	Programme level barriers to accessing feedback	Learners describe that feedback opportunities are not embedded in the programme.	There’s nothing sort of built into the program. That I mean, nothing might be strong, but there’s very little built into the program where you actually get feedback. I think we got feedback on like a short case, in second year, one time. (S3)
		Learners described having to navigate bureaucratic processes to access feedback.	You sort of can’t, well officially you can … but it’s really hard. So I never do, because there’s sort of no point, it’s too much of a headache (S19)
		Learners perceived supervisors to be very busy and that providing feedback to them was onerous and should not be expected.	I think I don’t want to bother people … when you’re in a hospital, and the people that are teaching, you have other issues at stake, they have to look after patients, and they are in a professional role … when it comes to teaching us, that’s probably lower on the list of priorities. So I just think it’s not something that I would think is that important to take up their time really to have to consider me and feedback towards me (S5)
		Learners describe being admonished for requesting feedback, both directly from supervisors, and advised by administrative staff that the policy was not to provide feedback	I feel like … the consultants are less approachable here, when it comes to asking for feedback, I don’t think I have ever asked for feedback here, just because I just don’t feel like it would be taken well.(S11) Sometimes they tell us, you’re not supposed to make contact, for feedback, because if you’re gonna get feedback, then everyone else is gonna want feedback (S23)
	Generic feedback common	Students will ask for feedback if it is likely to be specific to their performance: if they expect generic responses, they don’t.	I really like, specific points … please do X, Y, and Z. So anything that is the opposite of that, in terms of vagueness … just sort of providing critique, because it’s expected … (I leave a) feedback session being like, why did I even bother showing up? (S8) I feel like there’s just either zero feedback, or the feedback that we get is just like, ‘oh, you need to study more in this. study more of that’. It’s not. It’s not specific. (S11)
	Longitudinal feedback not often possible	students were more likely to seek feedback following repeated observation	I would ask someone, if I feel like, they’ve been seeing me enough to be able to have something to say (S34) So, the more knowledgeable a person is of my behaviours and (has)spent time with me, then I would (seek feedback) … be like, yeah, they actually know … they have, they’ve noticed the repetitive kind of patterns (S31)
FB Avoidance	Snapshot feedback common	Students sometimes actively avoid feedback when it is on a ‘snapshot’ of performance that they feel unrepresentative of their ability	Sometimes I’ll be with a reg (registrar) for like, two hours in clinic, you know, in that case, I might not ask because they wouldn’t have a whole lot to go on (S34) But it’s sort of hard to seek out. I think most of our lecturers don’t know us that well. Yeah, that well, so it’s kind of like, if you just email someone out of the blue, I feel like a lot of the time, they won’t even remember who you are by name (S39)
	Unsupportive leadership	Students actively avoid feedback which they perceive to be purposefully hurtful or have excessively high standards	If I feel like the person is just straight up being malicious … I’m not going to accept the feedback or even seek it. (S1) As I say like, there are some of the seniors doctors are like are really tough. Yeah. And then when they select you have present to them, I try to avoid them (S41)
Peers	Students turn to peers for feedback when it is not easy to access or is unhelpful	Students value asking peers for feedback to make sense of feedback and develop learning plans.	Do you ever give or seek feedback from other students? Yeah, definitely, all the time. And what does that look like? Really casual, friendly positive. It’s mostly around friends, rather than just random students. But like, there have been instances where you’re just randomly put with a student who is not your friend, and if they’re nice enough to help each other, like” Oh, no, you should do that better. And oh, no, we should do that better” It’s actually really positive, I tend to really like it.(S19) other times you didn’t do well. And you know, you didn’t do well. And so if you just need to sort of bounce ideas around with people, like if there’s something that you need to help understanding, then other students are good people for that (S34).

Table

Measure (number of items)	Sample item (Answered on a 6-point Likert scale, where 1 = strongly disagree and 6 = strongly agree)
Measure (number of items) Sample item Learning goal orientation (5)	I enjoy challenging and difficult tasks at work where I’ll learn new skills.
Performance goal orientation (8)	I’m concerned about taking on a task at work if my performance would reveal that I had low ability.
Perceived feedback benefits (6)	Feedback on my performance helps me to improve my work.
Perceived feedback costs (8)	It is not a good idea to ask your clinical lecturers/supervisors for feedback; they might think you are incompetent
Supportive leadership (9)	My clinical lecturer/supervisor is friendly and approachable.
Instrumental leadership (7)	My clinical lecturer/supervisor asks that students follow standard rules and regulations.
Measure (number of items)	Sample item (Answered on a 7-point Likert scale, where 1 = never and 6 = always)
Frequency of feedback inquiry (6)	How often do you ask your clinical supervisor for feedback on your performance?
Frequency of feedback monitoring (6)	How often do you try to read the behaviour of your clinical lecturer/supervisor?

Teunissen PW, Stapel DA, van der Vleuten C, et al. Who wants feedback? An investigation of the variables influencing residents’ feedback-seeking behavior in relation to night shifts. Acad Med. 2009;84(7):910–917. doi: 10.1097/ACM.0b013e3181a858ad

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