Research article
Open Access

Insight into undergraduate feedback of clinical practice: Junior Doctors vs Consultants

Agra Dilshani Hunukumbure[1], Ameen Jubber[1], Rohit Chitkara[1], Heather Bernand[1], Saroj Das[1]

Institution: 1. Hillingdon Hospital NHS Foundation Trust
Corresponding Author: Dr Agra Dilshani Hunukumbure ([email protected])
Categories: Students/Trainees, Teachers/Trainers (including Faculty Development), Teaching and Learning
Published Date: 10/04/2018

Abstract

Background: Constructive feedback is essential to improve clinical practice and is therefore discussed extensively in educational literature. Despite this, students regularly express dissatisfaction with their feedback at medical school. Many challenges to feedback in clinical settings have been documented but few were based on the students perspectives. This qualitative study explores the students experiences of feedback in clinical settings, in their third year at Imperial College London.

Method: Seven third year medical students who were based at Hillingdon Hospital during February 2014 were interviewed in a semi-structured format on their experience of feedback in clinical settings. The interviews were transcribed and analysed using a thematic analytical approach.

Results: The students claimed that they received little feedback and usually in an ad-hoc manner.  Feedback was inconsistent between different clinicians, confusing some participants. There was a marked difference in quality and quantity of feedback between the consultants and junior doctors, with the majority of students preferring feedback from juniors. Junior doctors feedback focussed on medical school assessments, whilst the consultants was geared towards daily clinical practice.

Discussion: Feedback provided by both clinician groups was heavily influenced by their own experiences and working environments. For consultants this was their vast clinical experience and considerable time constraints, whereas juniors had more time for students and could focus on exam techniques. Empowering students to take an active role in feedback, either seeking or clarifying the differences may be of help.

Conclusion: Though feedback from consultants and junior doctors is not aligned, both are useful in shaping future clinicians.

Keywords: Feedback in clinical settings; Feedback from junior doctors; Feedback from consultants; feedback challenges; Inconsistent feedback

Introduction

Feedback is a cornerstone of medical education and a dominating theme of the literature since the pioneering paper by Ende (Bing-You et al., 2017). It is frequently discussed at medical educational conferences (AMEE, 2017) and is an important component of the UK General Medical Council’s guidance for promoting excellence in medical education (General Medical Council, 2016).

Yet according to the UK National Student Survey, the average satisfaction across all Medical Schools for timely feedback and helpful comments was 61% and 59% respectively (Higher Education Funding Council for England, 2017). Ende described feedback as a formative, integral part of a student’s learning process, allowing the student to remain on course in reaching their goals (1983). It is the conduit through which good practice is reinforced and poor performance is modified (Cantillon & Sargeant, 2008).

Numerous factors have been described in the literature that hinders delivery of feedback. These can be categorised into teacher (e.g. lack of knowledge and experience) (Cantillon & Sargeant, 2008) student (e.g. unreliability of using student satisfaction as a metric) (Boehler et al., 2006)  and logistical (e.g. time and place restraints) (Ramani & Krackov, 2012) factors.

Though different approaches to feedback have been suggested and explored with students, few studies looked at the students’ experience in a clinical setting. The aim of this study was to explore the experience of third year medical students in receiving feedback on their clinical placements and investigate reasons for any dissatisfaction.

Method

Context

At Imperial College London, the first two years are pre-clinical studies, with third year comprising three ten-week hospital placements. They are assessed at the end of the year with written and practical examinations, where they are expected to show competencies in basic history taking, examination and clinical skills.

Study design

In this qualitative study, we used semi-structured interviews to explore individual experiences of receiving feedback. The interviews were transcribed and the data was analysed using a thematic analytical approach. Open and axial codes (as per Strauss and Corbin) were generated to identify the themes (1990). The students’ responses were anonymised, assigning each participant with a number.

Participants

Participants were recruited on a voluntary basis. The recruits were third year medical students at Hillingdon Hospital in February 2014. Seven students (males and females) participated. 

Ethics

Ethical approval was granted by the Medical Education Ethics Committee of Imperial College London (MEEC1314-11). We also obtained permission from the Research and Development Department of Hillingdon Hospital.

Results

We focused on the feedback challenges the students reported and have identified three main themes; sporadic feedback, inconsistent feedback and varying quality of feedback.

 

Sporadic Feedback

All study participants felt that they received insufficient feedback. One student took the initiative of actively seeking feedback from a clinician while many did not, unless there was a reinforcing factor such as a course requirement or recognition (Fig: 1).

Figure 1: Students’ quotes on sporadic feedback

 

Inconsistent feedback

The students were given inconsistent feedback by different clinicians. This differed from teaching they had previously received and some found this confusing.

“Everyone has different techniques, so there was always that area of ‘Why did you do that?’ and it’s like ‘Because that is what I was taught’”. S4

Interestingly, there was a distinct difference in feedback from consultants and junior doctors. Some students preferred the focus of the junior doctors (Figure: 2).

 

Figure 2: Students’ quotes on feedback from consultants and junior doctors.

 

Student response to inconsistent feedback

We explored the ways that the students responded to this diverse feedback (Figure 2). Though the feedback was incongruent, they did not mention this to the teachers. Instead, they tailored different approaches depending upon the teacher at the time. Some chose to only accept feedback from someone they could trust. One student mentioned someone ‘closer to the medical school’, who turned out to be a more senior medical student. In contrast, a few students managed to understand the context of the diverse feedback without hindering their overall learning.

 

Figure 3: Students’ reactions and interpretations on inconsistent feedback

 

Quality of feedback: Consultants vs Junior doctors

Students perceived a distinct difference in the content of feedback between consultants and junior doctors (Table 1). Students consistently highlighted generic feedback from consultants. More value was placed on junior doctors’ input.

 

Consultants

Junior doctors

“Consultant quite often just about ask you, how do you think you have been doing and then, whatever you say, is what goes on the form”. S3

“More a constant feedback process from them, we never really have a sit-down thing at the end of the firm”. S6

“Medical student should do this and its quite generic feedback especially with the sign off forms”. S6

“Juniors are better at giving more in depth feedback”. S7

“I have not heard a single consultant yet actually say, yes, you were good on this point, or you could improve in this area”. S6

“I think you get to know the Juniors a lot better and therefore they give more feedback”. S3

 

Table 1: Quality of feedback between consultants and junior doctors

 

Students’ interpretation of the varying quality of feedback

We explored the students’ beliefs into the reasons of different approaches between consultants and junior doctors (Figure 3). They identified consultants lack of time and direct observation of students as the key factors.

 

Figure 4: Students' views on causes of varying feedback

Discussion

We found that the students experienced inconsistent feedback in clinical settings, with a marked difference between the feedback of consultants and junior doctors. Feedback from junior doctors was impromptu and regular throughout the attachment, while the feedback from consultants was formal at the end of their placement. Our discussion focuses on exploring these differences.

Time            

The participants noted that more of their time was spent with junior doctors rather than consultants. This continuity of observation allowed junior doctors to accrue a more detailed account of their students’ performance and expectations.  As a result, feedback was perceived as being more comprehensive. Ende argued that ‘observation is the currency of feedback’ (1983 p:778). Our data demonstrated that without sufficient observation, feedback becomes increasingly generic and less personal (Table 1).

Conversely, consultants were noted to spend less time observing students. This may be due to two reasons. Firstly, consultants are increasingly dealing with administrative work and managerial roles in addition to their clinical and teaching duties (Appleby, 2017).  Secondly, consultants may devote their limited time with students to deliver teaching rather than observing and providing relevant feedback. Further studies could explore the consultants’ perception of this matter.

Content of feedback

Junior doctor’s feedback tended to be oriented towards helping students achieve exam success, whereas consultant feedback revolved around developing efficient clinical practice. This difference impacted the reception from students. With students expected to prepare standardised approaches for their examinations, they welcome feedback that helps them achieve this.  Although less clinically experienced than consultants, junior doctors seemed better equipped to fulfil this learning need due to their more recent experiences of undergraduate assessments.

Different level of experience and approximation to juniors

It is likely that due to their longer experience consultants can extract the information needed for clinical decision making from more focused examinations. In clinical practice, this approach increases efficiency, but can confound medical students, whose training emphasises systematic, thorough examinations. Students reported receiving feedback from consultants that, at times, appeared to contradict what they had previously been taught.

Feedback that contradicts previous learning could be demoralising and counterproductive. Exploring the students’ understanding and explaining the reasons for difference in practice may enhance learning. Students could be encouraged to clarify differences in practice and engage in discussion with their clinical teachers which may foster a deeper understanding of the subject. 

Junior doctors, being closer in time to their undergraduate training, are more likely to adopt clinical approaches that align with what students have been taught. Students will appreciate that junior doctors have recently successfully navigated the myriad of challenging assessments and portfolio requirements of medical school. It is likely that students will envision their role in the near future to be closer to that of a junior doctor than a consultant. As per Bandura’s social learning theory, learners are more likely to attend to and imitate those they perceive as being similar to themselves, who fulfill a role closer to theirs (1991).

More training at medical school

Medical school curricula have changed since the implementation of ‘tomorrow’s doctors’ by the General Medical Council (General Medical Council, 2016). Teaching and training students became the responsibility of doctors of all grades. In order to equip the next generation of doctors with these skills, medical schools often incorporate courses on teaching and feedback delivery. Perhaps this training at the undergraduate level is a factor contributing to the thorough feedback given by junior doctors, as perceived by medical students.

Student Initiative

Most of the literature and initiatives surrounding feedback focus on the role of the teacher in its delivery. However, as highlighted by one of our students, taking the initiative to actively seek feedback, outside compulsory forms, can be a highly effective method in maximising learning opportunities in clinical settings. Therefore, students could be encouraged to take an active role in their feedback.

Limitations and wider implications

Sample size was limited to seven participants. Therefore, we cannot generalise our findings to the whole cohort of students. But this study has improved our understanding on the feedback challenges faced by the students in clinical settings, enabling us to produce some recommendations. 

We did not explore the students’ contact time with each group of doctors, their seniority or specialities. These factors may influence feedback delivery and this may be worth further study.

Though all our study participants were from one university, the authors shared similar experiences at other institutions as undergraduates. Therefore, we believe the issues raised are common to many medical schools and a multi-institutional study could help determine the extent of these issues.

Conclusion

We conclude that feedback from both consultants and junior doctors is helpful for the development of medical students. Students preferred the junior doctors’ feedback relating to their medical school assessments. We believe that the consultants’ feedback is equally important in guiding them for their future roles as clinicians and fostering approaches needed to be an efficient clinical practitioner. Thus, feedback from both parties is essential for the students’ development.  Efforts should focus on helping students understand this duality and encouraging them to take an initiative in seeking or clarifying feedback from clinicians. This will result in greater quantity and improved perceptual quality of feedback and ultimately ameliorate student satisfaction.  

 

Take Home Messages

Initiatives could be implemented to gain benefit of feedback from both junior doctors and consultants. We have introduced a session at the beginning of the students’ placement highlighting the discrepancies and demonstrating how feedback from both groups of doctors could benefit their development. Organising drop-in tutorials to all doctors on the basic principles of feedback in clinical settings and better communication on undergraduate curriculum requirements may also be helpful in minimising the feedback dilemmas faced by students.

Notes On Contributors

Dr Agra Dilshani Hunukumbure: Lead Clinical Teaching Fellow Hillingdon Hospital, Honorary Lecturer Imperial College London

Dr Ameen Jubber: Clinical Teaching Fellow Hillingdon Hospital, Honorary Lecturer Imperial College London

Dr Rohit Chitkara; Clinical Teaching Fellow Hillingdon Hospital, Honorary Lecturer Imperial College London

Dr Heather Bernand: Clinical Teaching Fellow Hillingdon Hospital, Honorary Lecturer Imperial College London

Professor Saroj Das: Director of Clinical Studies Imperial College London, Vascular Surgeon Hillingdon Hospital

Acknowledgements

Professor Susan Smith, Head of Medical Education Research Unit, Imperial College London.

Bibliography/References

AMEE. (2017). AMEE Conference Programme. Retrieved from https://amee.org/getattachment/Conferences/AMEE-2017/AMEE-2017-Conference-Programme.pdf   

Appleby, J. (2017). How Productive are NHS Consultants? BMJ. 356:j1520.

https://doi.org/10.1136/bmj.j1520   

Bandura, A. (1991). Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes, 50(2), 248-287.

https://doi.org/10.1016/0749-5978(91)90022-L 

Bing-You, R., Hayes, V., Varaklis, K., Trowbridge, R., Kemp, H., & McKelvy, D. (2017). Feedback for learners in medical education: What is known? A scoping review. Academic Medicine, 92(9), 1346-1354.

https://doi.org/10.1097/ACM.0000000000001578   

Boehler, M. L., Rogers, D. A., Schwind, C. J., Mayforth, R., Quin, J., Williams, R. G., & Dunnington, G. (2006). An investigation of medical student reactions to feedback: a randomised controlled trial. Medical Education, 40(8), 746-749.

https://doi.org/10.1111/j.1365-2929.2006.02503.x   

Cantillon, P., & Sargeant, J. (2008). Giving feedback in clinical settings. BMJ (Clinical Research Ed.), 337, a1961.

https://doi.org/10.1136/bmj.a1961   

Ende, J. (1983). Feedback in clinical medical education. Jama, 250(6), 777-781.

https://doi.org/10.1001/jama.1983.03340060055026 

General Medical Council. (2016). Promoting excellence: standards for medical education and training. Retrieved from http://www.gmc-uk.org/education/standards.asp   

Higher Education Funding Council for England. (2017). National Student Survey 2017. Retrieved from https://unistats.ac.uk/Compare-Courses/Satisfaction   

Ramani, S., & Krackov, S. K. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 34(10), 787-791.

https://doi.org/10.3109/0142159X.2012.684916   

Strauss, A., & Corbin, J. M. (1990). Basics of qualitative research: Grounded theory procedures and techniques. (First ed.). London: Sage Publications, Inc.

Appendices

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Ken Masters - (08/05/2019) Panel Member Icon
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An interesting paper dealing with undergraduate feedback of clinical practice. Although the introduction is rather short, it does give some insight to the issues surrounding feedback from the literature. The comments about the content of the junior doctors’ feedback (focusing on exam success) as opposed to consultant feedback (focussing on medical practice) are especially noteworthy.

Some issues with the paper:
• The sample size is really small, and it would have been better if the authors had limited their sample through saturation processes rather pure convenience. While the information gathered is useful, we do not know how much extra relevant information exists. Although the authors acknowledge that this small sample size prevents generalisations, they begin their Conclusion with a generalisation “We conclude that feedback from both consultants and junior doctors is helpful for the development of medical students.” This broad generalisation simply cannot be inferred from this study. Similarly, because of the small sample and no discussion of saturation, it is difficult to support any of the statement made in the Conclusion, and this undermines the value of the paper.
• “Seven students (males and females) participated.” Numbers of each gender would be useful. Even in such a small sample, it is good to have some idea of the spread.
• Method of displaying the students’ comment. There is little or no purpose served in the different methods of display. The best method is simply to give the information in the standard format, rather than attempts at creative design. These simply become distractions to the message.
• In the Discussion, there is very little relating of the findings back to the literature. Although references are made to specific literature, statements like “Most of the literature and initiatives surrounding feedback focus on the role of the teacher in its delivery” without supplying any citations is rather weak.

So, the study has useful scope, but suffers from problems, the most severe of which is the value of the data because of the small sample and gathering techniques. It may be useful for the authors to repeat the study, using saturation processes, so that they at least have a stronger data set, and then being able to compare it more tightly to the findings in the literature.
Sateesh Babu Arja - (24/05/2018)
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I enjoyed reading this paper. This paper is useful to all medical programs in understanding the importance of providing effective feedback during clinical rotations. Formative assessments and feedback provide the necessary foundation for a future physician. To provide the effective feedback, the feedback needs to be focused and specific rather than generalized or vague and should be provided in a timely manner. Another key to providing effective feedback is feedback should be focused on strengths and how to improve the performance of the students in the future rather than just criticism. As Professor Fraser mentioned, junior doctors or residents have a chance or time to observe the medical students repeatedly compared to consultants. Repeated observations by physicians either planned or unplanned is crucial in providing feedback in the clinical setting.

Also, I would like to quote from Professor Fraser review that residents/junior doctors completed the program recently and they have contemporary knowledge of curriculum and assessments. To add to this, I would like to say faculty development activities are the key to the success of the implementation of formative assessments and providing feedback. Consultants and physicians are trained to be doctors rather than as teachers. They need frequent faculty development activities and to be updated in medical education. I would like to see what kind of faculty development activities are provided for consultants and residents. There are a lot of ways of providing formative feedback including Pendleton's formula where you start off with strengths and the weaknesses and always the students have the first choice to express their opinions. It is good to look at faculty development activities available for consultants and also to see if they are oriented to the learning objectives of the clerkship and assessment methods.

This paper is useful for faculty members/consultants and residents involved in clinical teaching and academic administrators.
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James Fraser - (13/04/2018) Panel Member Icon
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This paper adds to our understanding of student’s strategies for obtaining feedback in the clinical environment. One of the features of a feedback provider has been identified as the credibility of the individual providing the feedback. The credibility of the feedback provider has previously been reported as an important mediator in the acceptance of the feedback by the learner. This paper has identified that students perceive both junior medical staff and consultants as credible sources of feedback, albeit that the feedback provided focusses on different aspects of the student’s learning. The availability of junior staff allowing for repeated observation and ‘timely’ feedback along with their recent program completion, with contemporary knowledge of the curriculum and assessment requirements, has been identified as providing certainty and strategic guidance for assessment success.

The identification of different clinical approaches and techniques used by senior clinicians is challenging for medical students. Developing the understanding of having the ‘standardised’ methods representing a tool box of information gathering skills with tools selection influenced by experience is one approach, but it also falls to the senior staff to understand the medical student’s skill development level, and perhaps even think back to that stage in our own careers.

An important point raised by this paper is the amount of teaching and feedback that is undertaken by junior staff and the importance of providing them with some training in this area prior to graduation.