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      Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education


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          The 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.


          The 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.


          A 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?)


          Feedback 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 material

          The online version of this article (doi: 10.1007/s40037-015-0231-7) contains supplementary material, which is available to authorized users.

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          Most cited references 71

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          Assessing professional competence: from methods to programmes.

          We use a utility model to illustrate that, firstly, selecting an assessment method involves context-dependent compromises, and secondly, that assessment is not a measurement problem but an instructional design problem, comprising educational, implementation and resource aspects. In the model, assessment characteristics are differently weighted depending on the purpose and context of the assessment. Of the characteristics in the model, we focus on reliability, validity and educational impact and argue that they are not inherent qualities of any instrument. Reliability depends not on structuring or standardisation but on sampling. Key issues concerning validity are authenticity and integration of competencies. Assessment in medical education addresses complex competencies and thus requires quantitative and qualitative information from different sources as well as professional judgement. Adequate sampling across judges, instruments and contexts can ensure both validity and reliability. Despite recognition that assessment drives learning, this relationship has been little researched, possibly because of its strong context dependence. When assessment should stimulate learning and requires adequate sampling, in authentic contexts, of the performance of complex competencies that cannot be broken down into simple parts, we need to make a shift from individual methods to an integral programme, intertwined with the education programme. Therefore, we need an instructional design perspective. Programmatic instructional design hinges on a careful description and motivation of choices, whose effectiveness should be measured against the intended outcomes. We should not evaluate individual methods, but provide evidence of the utility of the assessment programme as a whole.
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            Beyond feedback: developing student capability in complex appraisal

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              State of the science in health professional education: effective feedback.

               Simon Archer (2009)
              Effective feedback may be defined as feedback in which information about previous performance is used to promote positive and desirable development. This can be challenging as educators must acknowledge the psychosocial needs of the recipient while ensuring that feedback is both honest and accurate. Current feedback models remain reductionist in their approach. They are embedded in the hierarchical, diagnostic endeavours of the health professions. Even when it acknowledges the importance of two-way interactions, feedback often remains an educator-driven, one-way process. An understanding of the various types of feedback and an ability to actively seek an appropriate approach may support feedback effectiveness. Facilitative rather than directive feedback enhances learning for high achievers. High-achieving recipients undertaking complex tasks may benefit from delayed feedback. It is hypothesised that such learners are supported by reducing interruptions during the task. If we accept that medical students and doctors are high achievers, we can draw on some guiding principles from a complex and rarely conclusive literature. Feedback should focus on the task rather than the individual and should be specific. It should be directly linked to personal goals. Self-assessment as a means to identify personal learning requirements has no theoretical basis. Motivated recipients benefit from challenging facilitated feedback from external sources. To achieve truly effective feedback, the health professions must nurture recipient reflection-in-action. This builds on self-monitoring informed by external feedback. An integrated approach must be developed to support a feedback culture. Early training and experience such as peer feedback may over time support the required cultural change. Opportunities to provide feedback must not be missed, including those to impart potentially powerful feedback from high-stakes assessments. Feedback must be conceptualised as a supported sequential process rather than a series of unrelated events. Only this sustained approach will maximise any effect.

                Author and article information

                Perspect Med Educ
                Perspect Med Educ
                Perspectives on Medical Education
                Bohn Stafleu van Loghum (Houten )
                30 November 2015
                30 November 2015
                December 2015
                : 4
                : 6
                : 284-299
                [ ]Keele University School of Medicine, Clinical Education Centre RSUH, ST4 6QG Staffordshire, UK
                [ ]Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
                [ ]Maastricht University and VU University Medical Center, Amsterdam, The Netherlands
                [ ]Isala Klinieken, Zwolle, The Netherlands
                © The Author(s) 2015

                Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

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