A total of 134 participants took part in the 17 focus groups: 53 undergraduate learners, 32 postgraduate learners and 49 physicians. The ways in which participants interpreted external feedback, both formal and informal, fell into several categories. We discuss these as (1) the interplay between experience, confidence, and fear of not appearing knowledgeable; (2) influences upon accessing, interpreting and using feedback; and (3) mechanisms guiding (and potentially biasing) interpretation of external feedback.
The interplay between experience, confidence (real and projected), and fear of not appearing knowledgeable
Throughout discussions of the role of the self in judging one’s performance and the readiness to accept feedback from other sources, it became clear that there remain fundamental differences of opinion across all groups with respect to how much learners and physicians should disclose to their patients, their colleagues, or themselves about their limitations. Some argued that lack of humility (i.e., the willingness to disclose one’s limitations) is a fundamental problem with some individuals’ practice.
You have to be able to say I made a mistake [or] I don’t know. So it’s kind of diametrically opposed to all of this training that you had that you are supposed to know and be confident and yet at the same time, you know you have to have this ability to look at yourself and say, I don’t know. [Physician M2]
Others argued that one should not disclose this lack of knowledge to patients as desirable features of practice to be strived for include independence and the projection of confidence.
I always tell people that there is nothing they can bring me that I can’t figure out … every symptom that they bring we will find a solution for … That may not even be true, but I tell them that with confidence. [Physician M3]
I had a patient have a PSA and I had never heard of a fractionated PSA and he had read about it on the internet and wanted to know about it. I said I had no idea. Found out pretty quickly, but not quick enough as he was gone from my practice immediately. [Physician M3]
Such situations were especially challenging for learners. They described trying to assess their competence in these challenging situations vis-a-vis the risk to the patient and the ramifications of appearing incompetent to others if they called for help.
You don’t want to show people you’re not capable of doing this. So that part of calling the doctors [when uncertain], I tend not to. Maybe [calling the doctors is] a good way, but it also makes me feel like I’m too weak to do it myself, so I try to do figure it out by myself. [Medical student I1]
That said, physicians too were susceptible to fear of not appearing knowledgeable and suggested that the fear of appearing not to know is a motivational factor, one participant expressing “the fear of looking really stupid.” [Physician L8].
With respect to enabling actual confidence, participants voiced opinions indicating that a large number of factors influenced their perceptions of their own performance, their motivations for wanting to perform well and their interpretation of externally generated information. A central and critical theme was that of experience. Experience was treated as a fundamental determinant of whether or not one is able to perform certain tasks. Both the absolute number of cases one has seen and the occurrence of specific experiences were thought to play a guiding role. However, little was mentioned in terms of the quality of either the experience or of the information gained from these experiences. That is, experience alone seemed to contribute to confidence and a sense of comfort.
If we had a particular number of patients whom I’ve [seen in] enough numbers, I’m confident that I can make most of the decisions without consulting my [senior] resident or attending. [Postgraduate O7]
For learners, experience was generally viewed positively, was desired, and generally led to increased confidence. Yet, confidence appeared tenuous and participants’ comments also made it clear that loss of confidence in response to particular events is something that needs to be overcome.
I think you lose confidence in yourself if you do something well and all of a sudden … you get a difficult one and then another difficult one, and then it’s, you know what, I can’t do that any more. [Postgraduate E5]
I can lose my confidence quite quickly, so I know that I could just put it off and avoid it and get other people to do it, but instead I try and bite the bullet and do it straight away, and then usually you’re really concentrating the next time, you think, I’ve gotta bloody get this one, and then you do it and then it’s fine. [Postgraduate E4]
“[T]he OSCE went really badly for me and I thought, oh, this is so bad that I don’t wanna think about it anymore. Like, the next OSCE’s miles away so I’ll worry about it later. But I did a portfolio piece on it and I kind of split up all the things that went wrong and thought of ways that, to fix it for next time. And if I hadn’t done portfolio I would’ve just left it and then probably [I’d] be in the same mess the next time round. [Medical student B6]
Indeed, confidence in one’s abilities, both in terms of its fragility and participants’ desire for it was a major theme when considering both trainees’ and physicians’ statements regarding the role of feedback. While participants clearly wanted feedback from others a number of statements implied that the desire could often be construed as wanting reassurance (i.e., as a source of confidence building rather than as a behaviour correction strategy).
I think I would rather have somebody else assess me than assess myself …. ‘cause it just gives me a bit more confidence that what I’m doing is right. [Medical student C6]
It sounds weird to be alone in such a big group of people, but you do feel like you kind of need someone to go ‘Yeah, that was great.’ [Medical student B3]
That is not to say that participants valued confidence at all costs as many did speak of the risk of becoming over-confident and described how one’s confidence needs to be informed by honest and humble self-appraisals of how they are doing:
“You know, if you think that you should be able to handle all things at all times, then you’re going to get into trouble, and you have to recognize, and that’s basically what self-assessment is, like, ‘I’m not terribly good at this, I don’t really get it all the time, and I need to know how to ask for help with that. [Physician A5]
In fact, participants’ responses suggested a paradox in that one needed to achieve a particular level of comfort, experience, and confidence prior to being prepared to ask for or receive corrective feedback. That is, confidence and experience appeared to work in two ways: By enabling participants to ask for and accept feedback and, for some, guarding them against feedback that might be critical in nature.
If you feel bad and you feel uncomfortable, you’re gonna not have the confidence to talk about mistakes, because if you already think that you’re a rubbish doctor, and then you do something which probably … is quite minor, but you know, you don’t get any kind of constructive feedback because you never say to anybody, you know, because you’re not comfortable saying it. [Postgraduate E6]
It might be a little paradoxical, the longer you are in practice the more prepared you are to admit you don’t know. Because, I think at that point, you don’t really care what people think, because hopefully you have developed a self esteem that is impervious to criticism. [Physician L8]
Influences on interpretation and uptake of external feedback
Some participants were cognizant that confidence alone could be an unreliable indicator of ability. A number of physicians spoke of the need to be shaken out of a prior belief and used emotionally-tied words like “shock” to express the feeling that first arises when discovering that there was a weakness in their performance. They further indicated a need to get over that feeling before the information could be utilized.
I don’t think that we are any more than human, and I think that you do get into ruts. … But I think there are people who just end up in ruts for a whole bunch of different reasons, and they know, they sorta stop thinking. It does require them to get a little bit of a jolt. [Physician J4]
So you get that initial shock, but then you think about it and look at are there potential reasons for this, or … you think about a potential solution. So you go beyond just, ‘what do [my colleagues] know.’ [Physician J2]
If it’s negative it always feels a bit painful. But it’s true, when you look upon yourself and you know she’s right, you can place it in a way. [Midwifery student G7]
The likelihood of such external information being utilized was very clearly thought to depend on the perceived credibility of the source, another dominant theme in the data. Emphasis was placed on the perceived accuracy of the feedback. Student participants discounted feedback provided by supervisors and others if they had not actually observed their performance. Family physicians likewise commented on critical consultants who did not understand the family physician’s role and patients who lacked the medical knowledge or insight required to objectively judge care. Some noted that the lack of opportunity to readily engage in collegial interactions creates difficulty “when you are in … solo practice” [Physician K7] and limits access to external feedback. Equally important was the need to believe that the feedback was delivered from a position of beneficence and non-maleficence, that belief often developing as a result of strong relationships being established between the feedback deliverer and recipient.
And it doesn’t mean that it is nice to hear it. It’s not so nice; you don’t feel so good after it. But it’s a difference when if it’s real, if what they’re saying is just to help you, or if it’s just to put you down. [Midwifery student F1]
If you have a supervisor who doesn’t care or that doesn’t give any feedback, then you aren’t going to work on it. [Medical student H3]
I think it depends on the consultant who you’re talking to. If it’s someone who really knows you and who has taken interest in you before, then you’ll be more willing to share and be honest, whereas if it’s someone you’ve seen once or twice, then you might be a bit hesitant to actually say that. [Medical student C7]
Most people don’t want to be exposed for their deficiencies unless they are comfortable with you. [Physician M3]
Mechanisms guiding (and potentially biasing) interpretation of external feedback
Throughout this discussion it appeared that respondents had any number of reasons to doubt the veracity of the external feedback received, thus reinforcing the notion that one must consider the recipient’s interpretation of the feedback conveyed if one hopes to alter the focal behaviour. This doubt was outright in some instances:
I think it’s quite difficult ‘cause like with examination stuff literally everyone does it differently … you can assess how good you are by kind of how confident you feel in what you’re doing, but you’ll never … do it exactly the same as someone else who might, you know, might say, ‘Oh, this is the right way.’ [Medical student C3]
In other instances, the doubt indicated by participants’ statements revealed potentially biased reasoning. That is, while the research design did not allow assessment of the accuracy of participants’ statements, their choice of words were sometimes suggestive of ways in which reasoning about one’s own performance could be led astray. For example, some expressed views that suggested a tendency to trust positive outcomes/feedback while discounting negative ones, thereby potentially increasing confidence by not accounting for the fact that positive outcomes can arise by chance just as readily as can negative outcomes. The relevant phrases have been underlined.
I was surprised that he gave me really positive feedback. And so that was useful to me because that was a real confidence booster when I wasn’t expecting it at all. But that’s about the only time I’ve found [feedback] useful. [Postgraduate E4]
I mean sometimes you’ll do it and somebody will watch you and it didn’t work and they’re like, ‘You did everything right, it’s just one of those things.’ But if it’s successful then I think, yeah, I can do that. [Postgraduate E2]
Adding to the potential for bias were statements reminiscent of the tendency humans have to attribute negative outcomes to situational (external) factors while attributing positive outcomes to one’s own skill.
…then sometimes you’re nervous, you’re always nervous when [your supervisor] comes. Then you do something wrong and you get this strange reaction and you start doing everything wrong. Afterwards the patient is well: I think he did well, but then the mentor says that it really wasn’t good enough. Then you feel hopeless because you did your best but everything went wrong because of the circumstances. [Midwifery student G2]
Some days I’ll go home and say I was a really good doc today and feel good about what happened in the day. And then other days you know, if I have a headache, maybe I wasn’t so good today. [Physician N7]
Finally, despite the discussion being focused on the use of external information to facilitate self-assessments, many participants made overarching statements about their confidence in their experience and “knowing enough.” These statements suggested that they remained of the opinion that at some fundamental level they were able to judge for themselves whether or not they are fit to practice in specific situations.
I think there are a lot of things I don’t know, but I think I know enough to make sure the patient doesn’t crash. [Postgraduate Q7]
That to me is a very important part of my self assessment where I feel that I know enough to know when to worry. [Physician L8]