Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents’ and 7 faculty members’ perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Ajjawi, R., & Higgs, J. (2008). Learning to reason: A journey of professional socialisation. Advances in Health Sciences Education,13(2), 133–150.
Bates, J., Konkin, J., Suddards, C., Dobson, S., & Pratt, D. (2013). Student perceptions of assessment and feedback in longitudinal integrated clerkships. Medical Education,47(4), 362–374.
Bing-You, R., Hayes, V., Varaklis, K., Trowbridge, R., Kemp, H., & McKelvy, D. (2017). Feedback for learners in medical education. Academic Medicine,92(9), 1346–1354.
Bing-You, R. G., Paterson, J., & Levine, M. A. (1997). Feedback falling on deaf ears: Residents’ receptivity to feedback tempered by sender credibility. Medical Teacher,19(1), 40–44.
Bok, H. G. J., Jaarsma, D. A. D. C., Spruijt, A., van Beukelen, P., van der Vleuten, C. P. M., & Teunissen, P. W. (2015). Feedback-giving behaviour in performance evaluations during clinical clerkships. Medical Teacher,38(1), 88–95.
Bok, H. G. J., Teunissen, P. W., Favier, R. P., Rietbroek, N. J., Theyse, L. F. H., Brommer, H., et al. (2013a). Programmatic assessment of competency-based workplace learning: When theory meets practice. BMC Medical Education,13(1), 123.
Bok, H. G. J., Teunissen, P. W., Spruijt, A., Fokkema, J. P. I., van Beukelen, P., Jaarsma, D. A. D. C., et al. (2013b). Clarifying students’ feedback-seeking behaviour in clinical clerkships. Medical Education,47(3), 282–291.
Boud, D., & Molloy, E. (2013). Rethinking models of feedback for learning: The challenge of design. Assessment and Evaluation in Higher Education,38(6), 698–712.
Brennan, J., & Olson, E. L. (2018). Advancing the profession. Nursing,48(10), 53–54.
Butler, D. L., & Cartier, S. C. (2018). Case studies as a methodological framework for studying and assessing self-regulated learning. In D. Schunk & J. Greene (Eds.), Handbook of self-regulation of learning and performance (2nd ed., pp. 352–369). NY: Routledge.
Castanelli, D. J., Jowsey, T., Chen, Y., & Weller, J. M. (2016). Perceptions of purpose, value, and process of the mini-clinical evaluation exercise in anesthesia training. Canadian Journal of Anaesthesia,63(12), 1345–1356.
Cuncic, C., Regehr, G., Frost, H., & Bates, J. (2018). It’s all about relationships: A qualitative study of family physicians” teaching experiences in rural longitudinal clerkships. Perspectives on Medical Education,7(2), 100–109.
Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., Carraccio, C., Swing, S. R., et al. (2010). Competency-based medical education: Theory to practice. Medical Teacher,32(8), 638–645.
Ginsburg, S., Eva, K., & Regehr, G. (2013). Do in-training evaluation reports deserve their bad reputations? A study of the reliability and predictive ability of ITER scores and narrative comments. Academic Medicine,88(10), 1539–1544.
Gordon, M. J. (1997). Cutting the Gordian knot: A two-part approach to the evaluation and professional development of residents. Academic Medicine,72(10), 876–880.
Govaerts, M. J. B., van der Vleuten, C. P. M., & Holmboe, E. S. (2018). Managing tensions in assessment: Moving beyond either-or thinking. Medical Education,85(2), 212–220.
Harris, P., Bhanji, F., Topps, M., Ross, S., Lieberman, S., Frank, J. R., et al. (2017). Evolving concepts of assessment in a competency-based world. Medical Teacher,39(6), 603–608.
Harrison, C. J., Könings, K. D., Dannefer, E. F., Schuwirth, L. W. T., Wass, V., & van der Vleuten, C. P. M. (2016). Factors influencing students’ receptivity to formative feedback emerging from different assessment cultures. Perspectives on Medical Education,5(5), 276–284.
Hattie, J., & Timperley, H. (2007). The power of feedback. Review of Educational Research,77(1), 81–112.
Heritage, M. (2018). Assessment for learning as support for student self-regulation. Australian Educational Researcher,45, 51–63.
LaDonna, K. A., Hatala, R., Lingard, L., Voyer, S., & Watling, C. (2017). Staging a performance: Learners’ perceptions about direct observation during residency. Medical Education,51(5), 498–510.
Lefroy, J., Watling, C., Teunissen, P. W., & Brand, P. (2015). Guidelines: The do’s, don’ts and don’t knows of feedback for clinical education. Perspectives on Medical Education,4(6), 284–299.
Lovell, B. (2017). What do we know about coaching in medical education? A literature review. Medical Education,38(3), 280–315.
Malhotra, S., Hatala, R., & Courneya, C.-A. (2008). Internal medicine residents’ perceptions of the mini-clinical evaluation exercise. Medical Teacher,30(4), 414–419.
Merriam, S. B. (2011). Third update on adult learning theory. In New directions for adult and continuing education. New York: Wiley.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis (2nd ed.). Thousand Oaks: SAGE.
Moroz, A., Horlick, M., Mandalaywala, N., & Stern, T. D. (2017). Faculty feedback that begins with resident self-assessment: Motivation is the key to success. Medical Education,50(2), 210–248.
Nicol, D. J., & Macfarlane-Dick, D. (2006). Formative assessment and self-regulated learning: A model and seven principles of good feedback practice. Studies in Higher Education,31(2), 199–218.
Norcini, J. J., Blank, L. L., Duffy, F. D., & Fortna, G. S. (2003). The mini-CEX: A method for assessing clinical skills. Annals of Internal Medicine,138(6), 476–481.
Ramani, S., Post, S. E., Könings, K., Mann, K., Katz, J. T., & van der Vleuten, C. (2017). “It’s just not the culture”: A qualitative study exploring residents perceptions of the impact of institutional culture on feedback. Teaching and Learning in Medicine,29(2), 153–161.
Schut, S., Driessen, E., van Tartwijk, J., van der Vleuten, C., & Heeneman, S. (2018). Stakes in the eye of the beholder: An international study of learners’ perceptions within programmatic assessment. Medical Education,52(6), 654–663.
Schuwirth, L. W. T., & van der Vleuten, C. P. M. (2011). Programmatic assessment: From assessment of learning to assessment for learning. Medical Teacher,33(6), 478–485.
Stigt, J. A., Koele, J. H., Brand, P. L. P., Jaarsma, D. A. C., & Slootweg, I. A. (2018). Workplace mentoring of residents in generic competencies by an independent coach. Perspectives on Medical Education,7(5), 337–341.
Tekian, A., Watling, C. J., Roberts, T. E., Steinert, Y., & Norcini, J. (2017). Qualitative and quantitative feedback in the context of competency-based education. Medical Teacher,39(12), 1245–1249.
Telio, S., Ajjawi, R., & Regehr, G. (2015). The “educational alliance” as a framework for reconceptualizing feedback in medical education. Academic Medicine,90(5), 609–614.
Telio, S., Regehr, G., & Ajjawi, R. (2016). Feedback and the educational alliance: Examining credibility judgements and their consequences. Medical Education,50(9), 933–942.
Turnbull, J., & Van Barneveld, C. (2002). Assessment of clinical performance: In-training evaluation. In International handbook of research in medical education (pp. 793–810). Dordrecht: Springer.
Urquhart, L. M., Ker, J. S., & Rees, C. E. (2017). Exploring the influence of context on feedback at medical school: A video-ethnography study. Advances in Health Sciences Education,46(3), 1018–1028.
Voyer, S., Cuncic, C., Butler, D. L., MacNeil, K., Watling, C., & Hatala, R. (2016). Investigating conditions for meaningful feedback in the context of an evidence-based feedback programme. Medical Education,50(9), 943–954.
Watling, C. (2014). Unfulfilled promise, untapped potential: Feedback at the crossroads. Medical Teacher,36(8), 692–697.
Watling, C., Driessen, E., van der Vleuten, C. P. M., & Lingard, L. (2012). Learning from clinical work: The roles of learning cues and credibility judgements. Medical Education,46(2), 192–200.
Watling, C., Driessen, E., van der Vleuten, C. P. M., & Lingard, L. (2014). Learning culture and feedback: An international study of medical athletes and musicians. Medical Education,48(7), 713–723.
Watling, C., & Ginsburg, S. (2019). Assessment, feedback and the alchemy of learning. Medical Education,53(1), 76–85.
Watling, C., LaDonna, K. A., Lingard, L., Voyer, S., & Hatala, R. (2016). “Sometimes the work just needs to be done”: Socio-cultural influences on direct observation in medical training. Medical Education,50(10), 1054–1064.
Weinstein, D. F. (2015). Feedback in clinical education: Untying the Gordian Knot. Academic Medicine,90(5), 559–561.
Weller, J. M., Jolly, B., Misur, M. P., Merry, A. F., Jones, A., Crossley, J. G. M., et al. (2009). Mini-clinical evaluation exercise in anaesthesia training. British Journal of Anaesthesia,102(5), 633–641.
Wiliam, D. (2011). Providing feedback that moves learning forward. In D. Wiliam (Ed.), Embedded formative assessment (pp. 107–132). Bloomington: Solution Tree Press.
Yin, R. (2018). Case study research and applications: Design and methods. Thousand Oaks: SAGE Publications Inc.
The authors thank the participating residents and faculty for their participation in this study.
This work was supported by a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
MacNeil, K., Cuncic, C., Voyer, S. et al. Necessary but not sufficient: identifying conditions for effective feedback during internal medicine residents’ clinical education. Adv in Health Sci Educ 25, 641–654 (2020). https://doi.org/10.1007/s10459-019-09948-8