Improving feedback literacy in a primary care rotation

Abstract

Primary care education is a unique clinical experience for medical students. It is community-based and provides an opportunity for students to learn consultation skills with multiple sources of workplace-based feedback. Meaningful and demonstrable utilisation of this feedback by students remains an educational challenge. We showcase achievable changes to educational tasks in an established curriculum, which aim to improve student feedback literacy and create a feedback loop which improves on previous provision of unidirectional, terminal feedback. The changes have been well-received, with student and educator engagement being positive. Students have demonstrated critical reflection on feedback, and development in consultation and clinical reasoning skills.

Keywords:

• Medical student
• feedback
• medical education
• primary care

What was the educational challenge?

Primary care education is a novel clinical experience for medical students. In contrast to hospital-based placements largely focused on instances of acute care, primary care is community-based and patient care models are holistic and continuous. It is the first opportunity for many students to encounter and consider issues specific to primary care including utilising clinical reasoning in the context of uncertainty, and formulating plans for patient management with appropriate safety netting and follow up. Many senior students will have a degree of proficiency in history taking and patient examination. Primary care rotations expose them to ‘the second half’ of the consultation, with management decisions needing to consider the specific social context of patients.

At our institution, students are placed with a general practice (GP) supervisor for much of their primary care rotation. There is a longer and more intimate association with specific clinics and supervisors than in typical hospital-based rotations as no more than 1–2 students will accompany a supervisor through the working day. Students have intermittent on-campus days to interact and engage in structured learning with their colleagues and GP medical educators.

The educational challenge revolved around student utilisation of received feedback. Historically, students have been observed in practice and given feedback on their performances, through both formative and summative exercises such as the mini clinical evaluation exercise (mini-CEX). Placement with primary care teams allows for multiple sources of feedback to be given, from educators, supervisors, clinic staff and patients. The feedback provided however, was unidirectional and terminal, with no further action from the student required, and no opportunity to demonstrate progression and receive further guidance. Student development and progression in consultation skills has been largely self-driven and unstructured. Though feedback may have helped students recognise discrepancies between what they were doing, and what they ought to do, there was no opportunity to develop and promote self-regulation (Launer 2016).

Feedback is a critical component of medical education. In primary care education, there is the opportunity for a combination of constructivist approaches with scaffolding provided by observation of GP supervisors and health care staff, and behaviourist approaches with discussion and reflection guiding students’ development of clinical reasoning and management skills. Feedback is only as good as its capacity to be utilised. Aiming to improve feedback literacy amongst medical students would allow them to appreciate feedback as an active and reciprocal process, giving them the skills to interpret and action received feedback, so they can recognise how this may help them further develop professionally and personally (Carless and Boud 2018).

What was the solution?

We sought to not only provide multiple instances of feedback, but create opportunities for students to reflect on, and action, this feedback. The aim was to complete the cycle of feedback which had previously been lacking. Existing assessments in clinical reasoning and consultation skills, were modified with oral presentations and provision of actionable feedback, requiring reflection to create a feedback loop. Students are assessed through a combination of mini CEX evaluations, oral presentations and OSCE-type assessments (Table 1).

Table 1. Modifications to existing assessment tasks.

Original task & assessment	Task with reflection on feedback
Written piece describing and analysing teamwork processes in primary care	Oral presentation to a small group of peers and experienced primary care medical educator. Follow up written reflective piece incorporating feedback from, and viewpoints of, peers and medical educator.
Observed mini-CEX with placement supervisor	Written reflection on challenges and improvements made from mini-CEX feedback, presented to examiner for consideration prior to final OSCE-type assessment.
Written case logs of clinically challenging presentations or questions presented to GP supervisor	Outcomes of case logs presented to a small group of peers and medical educator as a teaching exercise for students and learning opportunity / chance to provide feedback on learning.
OSCE-type assessment at the end of rotation involving a roleplaying actor (simulated patient)	Areas of improvement in consultation skills identified and shared by students with examiners and medical actors to prompt reflection on performance and areas for further improvement.

How was the solution implemented?

Consultation skills & team care

Primary-care specific consultation skills are introduced in interactive lectures at the start of the rotation, with simulated consultations involving role play amongst students forming a key component. Students are also introduced to the structure of and challenges faced by multidisciplinary care teams in the primary care setting in their introductory teaching block. When on placement, students, their supervisors, other healthcare and practice staff and patients are involved in helping students formulate an assessment of team care processes that they observe. This understanding was previously assessed with a written task.

Feedback in team care assessments

This task was changed to an oral presentation. Students present to a small cohort of their peers in the presence of an experienced GP medical educator. Subsequent feedback and discussion from their colleagues and GP medical educator inform further reflection on their perceptions of team care processes. This is presented as a written piece, which evidences the students’ reflection and development, and which must reference the ideas and views of their colleagues.

Feedback on Mini-clinical evaluation exercise (Mini-CEX) and role play assessment

Students are asked to reflect on feedback they have received from observed Mini-CEX assessments whilst on their clinical placements. This short, written piece is presented prior to an end-of-rotation OSCE-type assessment in which students demonstrate their progress, improvement, and proficiency in consultation skills with experienced roleplaying medical actors and a GP medical educator. The students’ goals for their performance in the assessment are discussed, post-hoc, with them, the GP medical educator and medical actor, constituting further provision of feedback on their performance and whether they were able to incorporate their own suggested changes and demonstrate improvement. This exercise aligns with the aim of creating a cycle of feedback, where students reflect on feedback received from multiple sources and explicitly state areas they have identified for improvement, thus demonstrating the impact of both constructivist and behaviourist types of learning, on their own clinical skills and practice. Being given an opportunity to demonstrate improvement, and the impact of feedback, better fits a composite definition of feedback which is, ‘specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance’ (van de Ridder et al. 2008).

Clinical reasoning

Students are encouraged to be self-directed in their learning with respect to identified gaps in clinical knowledge. Previously, case logs were kept by students to reflect on cases and research evidence-based answers and management solutions. These were presented, en bloc, to their supervisor at the end of their rotation for limited review and discussion.

Feedback on clinical case logs

To invite feedback and encourage participation in a community of practice, students now select cases they perceive to have educational value to present to their peers in small groups, to promote discussion amongst their colleagues and medical educators. With this input, students are encouraged to share their findings with their supervisors and patients who may have initiated the enquiry. This creates an opportunity to practically apply any feedback received and engenders a shared attitude of curiosity, with medical educators promoting the asking of questions, questioning of certainty, including their own, to enable open dialogue involving patients, learners and colleagues equally (Launer 2016). This task is formative and engages behaviorist approaches to learning and feedback, with the community of practice and senior educators helping students contextualise their learning and reshape their own interpretations. This guided reflection, with supportive challenge from an educator, helps students challenge underlying assumptions and consider new perspectives (Sandars 2009) to strengthen the metacognitive process of reflection and create a better understanding to inform future actions.

What lessons were learned that are relevant to a wider global audience?

Whilst this process is more labour-intensive, requiring further input from supervisors, GP medical educators, and students, it has had a substantial impact on fostering a stronger community of practice which forms the theoretical framework for primary care education at our institution (Cruess et al. 2018). There has been positive engagement from students with the provision of actionable feedback, as there is recognition of an opportunity to demonstrate improvement and development. Despite the workload implications, guided supervision is appreciated by students as a means of facilitating their reflection (Sandars 2009).

Engagement from medical educators has also been positive with a strengthening of the educational dyad that exists between learner and educator. Educators have reported increasing requests by students for their own insights into community-based patient care processes, clinical cases, and consultation skills. This contributes to the both constructivist and behaviourist feedback cycles where educators have more opportunities to provide scaffolding to help guide student learning and development. Furthermore, the increased time spent with supervisors and medical educators in the primary care rotation enhances the chances that students will accept constructive criticism as the teaching relationship is trusting and longer term and they will have started to become habituated to questioning, praise and suggestions for improvement (Launer 2016).

Most critically, the witnessed strengthening of an educational, primary-care focused community of practice is encouraging in the context of declining medical student interest in general practice and family medicine and projected shortages in the professional workforce. It is hoped that involving students in a supportive community of practice will foster greater interest in primary care careers or at least allow them to develop a greater understanding of the complexities of this field.

What are the next steps?

The program seeks to introduce longitudinal community-based primary care-focused education to medical students. Necessarily, the innovative combinations of feedback and reflection being used in the university environment will be expanded to include supervisors, other health staff and clinics based in community practice. There will need to be upskilling of physicians to engage with the improving feedback literacy and closing the feedback loop. Formal assessment of the impact of this push to increase and reflect on feedback to students would seek the views of students, educators, supervisors, clinical staff, and patients.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Michael Tran

Dr. Michael Tran, MBBS (Hons), BSc(Med)Hons, DCH, FRACGP, AFHEA, General Practitioner – Erskineville Doctors, Newtown, NSW, Australia, Lecturer – School of Population Health – University of New South Wales; Affiliations: University of New South Wales; Address/Telephone/Email: Cnr Botany and High Street, University of New South Wales, Kensington, NSW.

Joel Rhee

Associate Professor Joel Rhee, BSc(Med), MBBS(Hons), GCULT PhD, FRACGP, Discipline lead – General Practice and Primary Care, School of Population Health – University of New South Wales: Affiliations: University of New South Wales.

Oliver Smith

Dr Oliver Smith, MBChB, FRACGP, General Practitioner – Double Bay Doctors, Double Bay, NSW, Australia, Senior Lecturer – School of Population Health – University of New South Wales: Affiliations: University of New South Wales: Address/Telephone/Email: Cnr Botany and High Street, University of New South Wales, Kensington.