Using conversation analysis to explore feedback on resident performance

Abstract

Feedback on clinical performance of residents is seen as a fundamental element in postgraduate medical education. Although literature on feedback in medical education is abundant, many supervisors struggle with providing this feedback and residents experience feedback as insufficiently constructive. With a detailed analysis of real-world feedback conversations, this study aims to contribute to the current literature by deepening the understanding of how feedback on residents’ performance is provided, and to formulate recommendations for improvement of feedback practice. Eight evaluation meetings between program directors and residents were recorded in 2015–2016. These meetings were analyzed using conversation analysis. This is an ethno-methodological approach that uses a data-driven, iterative procedure to uncover interactional patterns that structure naturally occurring, spoken interaction. Feedback in our data took two forms: feedback as a unidirectional activity and feedback as a dialogic activity. The unidirectional feedback activities prevailed over the dialogic activities. The two different formats elicit different types of resident responses and have different implications for the progress of the interaction. Both feedback formats concerned positive as well as negative feedback and both were often mitigated by the participants. Unidirectional feedback and mitigating or downplaying feedback is at odds with the aim of feedback in medical education. Dialogic feedback avoids the pitfall of a program director-dominated conversation and gives residents the opportunity to take ownership of their strengths and weaknesses, which increases chances to change resident behavior. On the basis of linguistic analysis of our real-life data we suggest implications for feedback conversations.

Feedback and coaching

“…Learners are more receptive to feedback if it comes from a source that they perceive as credible [ 14 ]. Presenting feedback in a dialogue between learner and supervisor instead of a one-way transfer of information from supervisor to learner acknowledges the social and emotional intricacies of human relationships, which also supports acceptance of the feedback provided, and acting upon it [ 21 ]. This is also supported by limiting the amount of feedback to one to three key points of the observed task.…”

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

“…Clinical supervisors can use feedback to support learners’ growth towards increasing autonomy and independent practice by forming educational alliances with their learners [ 6 ], engaging with learners in informed self-assessment and reflection, and co-creating a safe learning environment with their learners [ 4 , 7 ]. Recent research unravelling the complexities of feedback conversations in clinical education is thought to help clinical supervisors to provide frequent constructive feedback to their learners [ 2 , 5 , 7 , 8 ], and to inform faculty development initiatives to improve clinical supervisors’ feedback conversation techniques [ 9 – 11 ].…”

“…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 ].…”

“…Feedback framed as repeated coaching over time aimed at improving clinical skills promotes the acceptance of feedback and acting upon it [ 36 , 38 ]. Designing feedback as a dialogue gives learners the opportunity to take ownership of their strengths and weaknesses [ 8 ]. Particularly when the feedback comments given are specific, detailed, take into consideration what effect the feedback will have, and are personalised to the learner’s own work, this will help learners to change their behaviour and improve their performance [ 9 , 39 ].…”

“…Learners should also be reassured that such high-stakes judgements can never come as a surprise, because any concern among the team of supervisors about the learner’s performance or growth in competence will be discussed with the learner at an early stage [ 9 , 28 ]. All supervisors should be trained in methods for effective feedback conversations, highlighting the importance of trust and mutual engagement in these conversations [ 7 , 8 , 53 , 54 ].…”