General Internal Medicine, University of Toronto, Toronto, Ontario, Canada.
Division of General Internal Medicine, University Health Network and Faculty of Medicine, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada.
J Gen Intern Med. 2019 Oct;34(10):2107-2113. doi: 10.1007/s11606-019-05134-z. Epub 2019 Aug 6.
The case presentation is a fundamental activity used in both patient care and trainee education, partly due to feedback from supervisor to trainee. Although feedback in medical education is well studied, prior studies have not focused on the perceptions of feedback by Internal Medicine supervisors and trainees as it relates to clinical activities like the case presentation.
Semi-structured interviews were conducted with eight Internal Medicine physicians, and 18 Internal Medicine trainees (5 medical students, 13 residents) at the University of Toronto. Purposive sampling was used. Interviews were conducted and coded iteratively within a constructivist grounded theory approach until saturation was reached.
Supervisors and trainees recognized feedback as an important part of the case presentation that can be (1) explicit, labeled feedback or (2) implicit, unlabeled feedback. Both trainees and supervisors perceived that not enough feedback occurs, likely stemming from a hesitancy by supervisors to label implicit feedback, calling it an interruption instead. Although trainees were keenly aware of non-verbal feedback from their supervisors as implicit feedback, they often interpreted explicit constructive feedback negatively. Interestingly, the same feedback from senior residents was regarded as highly educational, as it was uncoupled from assessment.
Feedback occurs more frequently in case presentations than previously described, particularly in an implicit, unlabeled format. Even though under-recognized, trainees identify and utilize implicit feedback from supervisors, and coaching from senior residents, to develop learned behaviors. This is reassuring in the age of Competency-Based Medical Education, as feedback has an essential role in workplace-based assessment and promotion.
病例汇报是医患互动和医学生教学的基本活动，其部分价值体现在上级医生对下级医生的反馈中。尽管医学教育领域对反馈的研究由来已久，但既往研究多关注临床工作以外的反馈，如教育性反馈，而对病例汇报中临床活动相关的反馈重视不足。
我们对 8 名内科医生和 18 名内科住院医师（5 名医学生，13 名住院医师）进行了半结构化访谈。采用目的抽样法，访谈内容和编码采用建构主义扎根理论方法，直至达到饱和。
带教医生和住院医师都认为反馈是病例汇报的重要组成部分，可以是（1）明确的、有标签的反馈，也可以是（2）隐含的、无标签的反馈。带教医生和住院医师都认为反馈不足，可能是因为带教医生不愿对隐含的反馈进行标签化，认为这是一种打断。尽管住院医师敏锐地意识到上级医生的非言语反馈是隐含的反馈，但他们往往会对明确的建设性反馈产生负面反应。有趣的是，上级住院医师的同样反馈被认为是高度教育性的，因为它与评估无关。
病例汇报中的反馈比之前描述的更为频繁，尤其是以隐含的、无标签的形式出现。尽管反馈没有得到充分的认识，但住院医师可以识别和利用上级医生和上级住院医师的隐含反馈以及指导，以培养习得行为。在以能力为基础的医学教育时代，反馈在基于工作场所的评估和晋升中具有重要作用，因此这一发现令人欣慰。
