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      The impact of patient feedback on the medical performance of qualified doctors: a systematic review

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          Abstract

          Background

          Patient feedback is considered integral to quality improvement and professional development. However, while popular across the educational continuum, evidence to support its efficacy in facilitating positive behaviour change in a postgraduate setting remains unclear. This review therefore aims to explore the evidence that supports, or refutes, the impact of patient feedback on the medical performance of qualified doctors.

          Methods

          Electronic databases PubMed, EMBASE, Medline and PsycINFO were systematically searched for studies assessing the impact of patient feedback on medical performance published in the English language between 2006-2016. Impact was defined as a measured change in behaviour using Barr’s (2000) adaptation of Kirkpatrick’s four level evaluation model. Papers were quality appraised, thematically analysed and synthesised using a narrative approach.

          Results

          From 1,269 initial studies, 20 articles were included (qualitative ( n=8); observational ( n=6); systematic review ( n=3); mixed methodology ( n=1); randomised control trial ( n=1); and longitudinal ( n=1) design). One article identified change at an organisational level (Kirkpatrick level 4); six reported a measured change in behaviour (Kirkpatrick level 3b); 12 identified self-reported change or intention to change (Kirkpatrick level 3a), and one identified knowledge or skill acquisition (Kirkpatrick level 2). No study identified a change at the highest level, an improvement in the health and wellbeing of patients. The main factors found to influence the impact of patient feedback were: specificity; perceived credibility; congruence with physician self-perceptions and performance expectations; presence of facilitation and reflection; and inclusion of narrative comments. The quality of feedback facilitation and local professional cultures also appeared integral to positive behaviour change.

          Conclusion

          Patient feedback can have an impact on medical performance. However, actionable change is influenced by several contextual factors and cannot simply be guaranteed. Patient feedback is likely to be more influential if it is specific, collected through credible methods and contains narrative information. Data obtained should be fed back in a way that facilitates reflective discussion and encourages the formulation of actionable behaviour change. A supportive cultural understanding of patient feedback and its intended purpose is also essential for its effective use.

          Electronic supplementary material

          The online version of this article (10.1186/s12909-018-1277-0) contains supplementary material, which is available to authorized users.

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          Most cited references44

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          Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

          Background Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK Methods This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. Results Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research. Discussion By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.
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            An evidence-based practice guideline for the peer review of electronic search strategies.

            Complex and highly sensitive electronic literature search strategies are required for systematic reviews; however, no guidelines exist for their peer review. Poor searches may fail to identify existing evidence because of inadequate recall (sensitivity) or increase the resource requirements of reviews as a result of inadequate precision. Our objective was to create an annotated checklist for electronic search strategy peer review. A systematic review of the library and information retrieval literature for important elements in electronic search strategies was conducted, along with a survey of individuals experienced in systematic review searching. Six elements with a strong consensus as to their importance in peer review were accurate translation of the research question into search concepts, correct choice of Boolean operators and of line numbers, adequate translation of the search strategy for each database, inclusion of relevant subject headings, and absence of spelling errors. Seven additional elements had partial support and are included in this guideline. This evidence-based guideline facilitates the improvement of search quality through peer review, and thus the improvement in quality of systematic reviews. It is relevant for librarians/information specialists, journal editors, developers of knowledge translation tools, research organizations, and funding bodies.
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              State of the science in health professional education: effective feedback.

              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.
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                Author and article information

                Contributors
                julian.archer@plymouth.ac.uk
                Journal
                BMC Med Educ
                BMC Med Educ
                BMC Medical Education
                BioMed Central (London )
                1472-6920
                31 July 2018
                31 July 2018
                2018
                : 18
                : 173
                Affiliations
                [1 ]ISNI 0000 0001 2219 0747, GRID grid.11201.33, Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Faculty of Medicine and Dentistry, , University of Plymouth, ; Drake Circus, Plymouth, PL4 8AA UK
                [2 ]ISNI 0000000121901201, GRID grid.83440.3b, Improvement Science London, , University College London, ; London, UK
                [3 ]ISNI 0000000121901201, GRID grid.83440.3b, Research Department of Primary Care and Population Health, , University College London, ; London, UK
                Author information
                http://orcid.org/0000-0001-9983-9655
                Article
                1277
                10.1186/s12909-018-1277-0
                6069829
                30064413
                f9950425-65e6-4aab-80ea-3bdb2eea435c
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 27 June 2017
                : 11 July 2018
                Funding
                Funded by: General Medical Council
                Award ID: 152
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Education
                patient feedback,systematic review,medical education,impact,behaviour change,doctors
                Education
                patient feedback, systematic review, medical education, impact, behaviour change, doctors

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