The Research Contributions of Family Medicine Educators to Medical Learner Feedback

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11th Feb 2020 Nursing Essay Reference this

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ABSTRACT

Background and objectives

Feedback has been a focus of the medical education literature for decades and its scope is far-ranging. In 2016, we performed a scoping review as a means of mapping and integrating what is known in the literature about feedback to medical learners. In this descriptive analysis, we explore the contribution of family medicine educators to the medical education feedback literature.

Methods

Nineteen articles extracted from our original scoping review plus six articles identified from an additional search of the journal Family Medicine are described in-depth.

Results

The proportion of articles involving family medicine educators identified in our scoping review is small (n=19/650, 3%) and the total number (25) remains low after including the additional articles (n=6) from the Family Medicine search. The five year-period between 2010-2015 includes a greater number of articles (n=11) than in either of the preceding two decades (n=7 in 1990-1999, n=6 in 2000-2009). The articles in this review encompass a broad range of feedback methods and performance improvement goals. The articles are mostly of a non-rigorous design (n=14) and primarily originated in the United States (n=19) and Canada (n=3) within Family Medicine Departments (n=20).

Conclusions

The contributions of family medicine educators to the medical education literature on feedback to learners is sparse and mostly of a non-rigorous study design. Promisingly, the contribution of well-designed studies by family medicine educators in this area appears to be increasing.

 

INTRODUCTION

 

Feedback has been a focus of the medical education literature for decades and its scope is far-ranging.  The feedback literature encompasses discussions of a variety of features, techniques and purposes. Feedback has been deemed essential to promoting learning1, improving performance2, acquiring clinical skills3 and more recently, meeting standards of competency.4 In 2016, we performed a scoping review5 as a means of mapping and integrating what is known in the literature about feedback to medical learners.6 In this descriptive analysis, we explore the contribution of family medicine educators to the medical education feedback literature by extending our scoping review work and completing an evidence synthesis for a subset of articles.7 

As a specialty, family medicine stands in an ideal position to contribute to the medical education literature due to a scope of practice that spans all ages, all sexes, and all organ systems. Family medicine physicians train learners to manage patients within the family context and navigate the health care system with a breadth that integrates the biological, clinical and behavioral sciences.8  In Webster’s 2015 scoping review 9 ofthe state of medical education research in Family Medicine, the authors identified the most common broad topic areas of research focus, such as continuing education and curriculum development, and highlighted a general lack of methodological sophistication. They recommended examining specific topic areas in greater depth. In light of the importance of feedback in medical training,10 we sought to explore the contribution of family medicine educators to the medical education literature on feedback to learners.

METHODS

From the 650 articles included in the initial scoping review, 19 were identified that involved family medicine learners or educators.

In order to assess the integrity of the acquisition of articles for our scoping review,6 an additional search was conducted in the journal Family Medicine. The more extensive search string that was utilized in our scoping review6 (feedback; feedback, psychological; medical students; assessment; self-assessment; internship and residency; resident; fellows; medical education; faculty; faculty, medical; reflection) was not an option in the search function capabilities of this journal.  The search terms feedback or assessment were utilized. After cross-referencing articles with those captured in our scoping review, an additional six articles were identified that were felt by us to warrant inclusion.

 

The nineteen articles extracted from our original scoping review plus the six articles identified from the additional search of Family Medicine provide the basis for this descriptive analysis (Table 1).11-35

RESULTS

A total of 25 articles, with years of publication ranging from 1985 to 2015, were reviewed in-depth (Table 1).

Year

One article was published prior to 1990 (4%),32 seven articles (28%) were published between 1990-199917,18,20,24,29,30,34 and six (24%) between 2000-2009.15,21-23,27,28 Eleven manuscripts (44%) were published in 2010 or thereafter.11-14,16,19,25,26,31,33,35

Learners

In the seventeen studies (68%) in which learners participated directly (as opposed to an opinion paper, faculty interview or thesis), family medicine residents were involved exclusively in nine studies (36%)11,13,17,25,26,30,31,33,35 or with other resident specialties in an additional three (12%).12,16,34 Medical students on a family medicine clerkship were involved in the remaining five studies (20%).14,19,24,29,32

Investigators

Most of the opinion papers and studies were written or conducted, respectively, by family medicine educators within a Family Medicine Department) (n=20, 80%)11-15,17,18,20-26,28-33,35 or within a Dept. of Medical Education (n=3, 12%).16,22,27 One study was conducted by internal medicine physicians (4%)34 and one by psychiatry in collaboration with family medicine (4%).19

Methodology

Three (12%)19,31,35 of the studies employed a randomized controlled trial (RCT) study design.  Eight studies (32%)11,14,17,24,30,32-34 utilized a quasi-experimental, uncontrolled before and after format. Five of the articles (24%)18,20,21,23,28 consisted of opinion papers, one (4%)15 involved a limited literature review, one (4%)22 summarized a doctoral thesis and one was a correlational study (4%).26 The remainder of the studies (n=6, 24%)12,13,16,25,27,29 utilized a combination of surveys, interviews and focus groups.

 

Feedback focus

The thirteen studies that included an intervention (52%) targeted a variety of topics including communication proficiency (n=4, 16%),11,19,24,32 clinical skills such as diagnostic accuracy and clinical reasoning (n=3, 12%),14,31,34 self-assessment (n=2, 8%),17,29 documentation accuracy (such as medical coding and prescription-writing) (n=2, 8%),30,33 peer or multi-source feedback (n=1, 4%)13 and teaching skills (n=1, 4%).35

Feedback formats

In studies employing an intervention (n=13, 52%), the most common feedback formats included direct verbal one-on-one communication (n=3, 12%)11,14,31 or written feedback (n=5, 20%).19,30,33-35 Feedback also occurred in association with videotaped sessions (n=3, 12%),17,24,32 standardized patient activities (n=1, 4%)29 and online by peers (n=1, 4%).13

Location

Approximately three-quarters of the studies were conducted in the United States (n=19, 76%).11,13,14,15,19,20,21,23-26,28,29-35 Three were Canadian studies (12%)12,22,27 and two were conducted in Australia (8%).17,18 One study involved the United States, Canada and three additional countries (4%).16

DISCUSSION

This study contributes to the family medicine literature by highlighting the contributions of family physicians in the area of learner feedback, a topic considered by many to be a central one in medical education.36,37 The number of articles in this analysis are too small to draw any strong conclusions about trends in family medicine research but several findings are notable. The articles encompass a broad range of feedback methods and performance improvement goals as opposed to a specific feedback subject area. Most of the studies are being conducted in the United States and Canada (93%) within Family Medicine Departments (80%). The overall number of studies involving family medicine educators represents a small proportion of the feedback literature identified in our scoping review; in fact, only 3% (n=19/650) of the studies involved family medicine. The number remained small (25 total) in spite of the additional search of Family Medicine.  It is promising that the number of articles published in the five year-period between 2010-2015 is greater than in either of the preceding two decades and may indicate that the family medicine research field in this area is expanding.

Limitations in methodological approach and lack of detailed reporting have been expressed as a concern in family medicine education research.9 This review included only three randomized controlled trials.  Most of the intervention studies utilized a simple quasi-experimental before and after format. The feasibility of utilizing randomization and blinding with medical learners has been called into question by some, as well as the advisability of using research models from the clinical realm to explore the highly complex system of medical education.38 Medical education research may lend itself more readily to descriptive and clarification studies rather than the gold standard of randomized controlled trials.39 Attention to elements such as the use of a comparison group, adequate numbers, recognizing bias and a thoughtful discussion of limitations may be more important than a concentration on a specific study design.38 The three RCT studies in this analysis are fairly recent studies (2012, 2014 & 2015) and show that this methodology can be feasible in certain instances.

Limitations

It is possible that all feedback articles for medical learners may not have been captured in the initial scoping review or subsequent search of Family Medicine.  The small number of studies makes it difficult to draw strong conclusions. This analysis involved only publications related to feedback for helping medical learners.  Including studies addressing continuing medical education for faculty, the largest focus of medical education research in the Family Medicine literature,9 would increase the number available for analysis on the topic of feedback.

CONCLUSION

The contributions of family medicine educators to the medical education literature on feedback to learners is sparse and mostly of a non-rigorous study design. Promisingly, the contribution of well-designed studies by family medicine educators in this area appears to be increasing.

 

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