IntroductionThe guidelines offered in this paper aim to amalgamate the literature on formative feedback into practical Do’s, Don’ts and Don’t Knows for individual clinical supervisors and for the institutions that support clinical learning.MethodsThe authors built consensus by an iterative process. Do’s and Don’ts were proposed based on authors’ individual teaching experience and awareness of the literature, and the amalgamated set of guidelines were then refined by all authors and the evidence was summarized for each guideline. Don’t Knows were identified as being important questions to this international group of educators which if answered would change practice. The criteria for inclusion of evidence for these guidelines were not those of a systematic review, so indicators of strength of these recommendations were developed which combine the evidence with the authors’ consensus.ResultsA set of 32 Do and Don’t guidelines with the important Don’t Knows was compiled along with a summary of the evidence for each. These are divided into guidelines for the individual clinical supervisor giving feedback to their trainee (recommendations about both the process and the content of feedback) and guidelines for the learning culture (what elements of learning culture support the exchange of meaningful feedback, and what elements constrain it?)ConclusionFeedback is not easy to get right, but it is essential to learning in medicine, and there is a wealth of evidence supporting the Do’s and warning against the Don’ts. Further research into the critical Don’t Knows of feedback is required. A new definition is offered: Helpful feedback is a supportive conversation that clarifies the trainee’s awareness of their developing competencies, enhances their self-efficacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur.Electronic supplementary materialThe online version of this article (doi: 10.1007/s40037-015-0231-7) contains supplementary material, which is available to authorized users.

Transition is a step change in responsibility for which total preparedness is not achievable. This transition is experienced as a rite of passage when the newly qualified doctor first makes decisions alone. This study extends the existing literature by explaining the mechanisms involved in preparedness for firsts.

Context: While formative workplace based assessment can improve learners' skills, it often does not because the procedures used do not facilitate feedback which is sufficiently specific to scaffold improvement. Provision of pre-formulated strategies to address predicted learning needs has potential to improve the quality and automate the provision of written feedback. Objectives:To systematically develop, validate and maximise the utility of a comprehensive list of strategies for improvement of consultation skills through a process involving both medical students and their clinical primary and secondary care tutors.Methods: Modified Delphi study with tutors, modified nominal group study with students with moderation of outputs by consensus round table discussion by the authors.Results: 35 hospital and 21 GP tutors participated in the Delphi study and contributed 153 new or modified strategies. After review of these and the 205 original strategies, 265 strategies entered the nominal group study to which 46 year 4 and 5 students contributed, resulting in the final list of 249 validated strategies. Conclusions:We have developed a valid and comprehensive set of strategies which are considered useful by medical students. This list can be immediately applied by any school which uses the Calgary Cambridge Framework to inform the content of formative feedback on consultation skills. We consider that the list could also be mapped to alternative skills frameworks and so be utilised by schools which do not use the Calgary Cambridge Framework.

ContextGrades are commonly used in formative workplace-based assessment (WPBA) in medical education and training but may draw attention away from feedback about the task. The dilemma is that the selfregulatory focus of a trainee must include self-awareness relative to agreed standards, which implies grading.In this study we aimed to understand the meaning which medical students construct from WPBA feedback with and without grades, and what influences this. MethodsYear 3 students were invited to take part in a randomised crossover study in which each student was their own control. Each student had one WPBA with and one without grades, and then chose whether or not to have grades with their third WPBA. These preferences were explored via semi-structured interviews. A realist approach to analysis was used to gain understanding of student preferences and the impact of feedback with and without grades. Results and discussionOf students who had feedback with and without grades, 65 (78%) then chose to have feedback with grades and 18 (22%) without grades their third WPBA. 24 students were interviewed.Students described how grades locate their performance and calibrate their self-assessment. For some, low grades focused attention and effort. Satisfactory and high grades enhanced self-efficacy.Grades are also concrete, powerful and blunt, can be harmful and need explanation to help students create helpful meaning from them. Low grades risk reducing self-efficacy in some and may encourage others to focus on proving their ability rather than on improvement.A metaphor of the semi-permeable membrane is introduced to understand how students reduced potential negative effects and enhanced the positive effects of feedback with grades by selective filtering and pumping. ConclusionThis study illuminates the complexity of the processing of feedback by its recipients, and informs the use of grading in provision of more effective, tailored feedback.

Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov's narrative framework (Labov in J Narrat Life Hist 7(1-4):395-415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight.