Resident Perceptions of Assessment and Feedback in Competency-Based Medical Education: A Focus Group Study of One Internal Medicine Residency Program

Abstract

Purpose As key participants in the assessment dyad, residents must be engaged with the process. However, residents’ experiences with competency-based medical education (CBME), and specifically with entrustable professional activity (EPA)-based assessments, have not been well studied. The authors explored junior residents’ perceptions regarding the implementation of EPA assessment and feedback initiatives in an internal medicine program. Method From May to November 2018, 5 focus groups were conducted with 28 first-year internal medicine residents from the University of Toronto, exploring their experiences with facilitators and barriers to EPA-based assessments in the first years of the CBME initiative. Residents were exposed to EPA-based feedback tools from early in residency. Themes were identified using constructivist grounded theory to develop a framework to understand the resident perception of EPA assessment and feedback initiatives. Results Residents’ discussions reflected a growth mindset orientation, as they valued the idea of meaningful feedback through multiple low-stakes assessments. However, in practice, feedback seeking was onerous. While the quantity of feedback had increased, the quality had not; some residents felt it had worsened, by reducing it to a form-filling exercise. The assessments were felt to have increased daily workload with consequent disrupted workflow and to have blurred the lines between formative and summative assessment. Conclusions Residents embraced the driving principles behind CBME, but their experience suggested that changes are needed for CBME in the study site program to meet its goals. Efforts may be needed to reconcile the tension between assessment and feedback and to effectively embed meaningful feedback into CBME learning environments.

Driving lesson or driving test?: A metaphor to help faculty separate feedback from assessment

“…Despite these advancements in our understanding of the usefulness and the optimal provision of feedback, medical learners continue to experience a limited amount of feedback during their clinical placements, receive feedback that is too general or limited in scope to be helpful, and engage with faculty deficient in feedback competencies [ 1 , 5 , 8 , 12 , 13 ]. Recent observations suggest that competency-based medical education creates tension between feedback intended to support a learner’s growth and the formal assessment procedures needed to assess the acquisition of the core competencies of the programme [ 13 , 14 ].…”

“…Despite these advancements in our understanding of the usefulness and the optimal provision of feedback, medical learners continue to experience a limited amount of feedback during their clinical placements, receive feedback that is too general or limited in scope to be helpful, and engage with faculty deficient in feedback competencies [ 1 , 5 , 8 , 12 , 13 ]. Recent observations suggest that competency-based medical education creates tension between feedback intended to support a learner’s growth and the formal assessment procedures needed to assess the acquisition of the core competencies of the programme [ 13 , 14 ]. Learners tend to perceive learning activities like direct observation of clinical skills as high-stakes evaluations with significant consequences for their future [ 14 – 17 ], prompting them to avoid feedback opportunities associated with direct observations [ 18 – 20 ], and hence missing out on the potentially very useful feedback associated with it.…”

“…Although the importance of distinction between feedback and assessment has been stressed for more than 20 years [ 23 ], clinical supervisors continue to confuse and blend feedback and assessment to this day [ 5 , 13 , 24 , 25 ]. This suggests that the methods to teach them about this distinction and its importance should be improved.…”

“…They “play the game” of seeking only positive feedback (i.e. only ask for feedback on a task or procedure they think they did well) [ 13 , 31 , 34 ]. They use these positive assessments to buff their portfolios.…”

“…They use these positive assessments to buff their portfolios. They believe that this proves their clinical competence, which will lead their supervisors to sign off on their entrustable professional activities, in-training evaluation reports, or annual progress assessments [ 13 , 32 ]. Residents employ this and other impression management strategies to portray an image of competence [ 13 , 25 , 35 ].…”