Regarding the feedback received

In the group of interns, it was reported that it was the first time they had contact with that type of assessment (Mini-CEX), which included a feedback time. The assessed individuals considered in a solid and frequent manner the fact that they did not receive effective feedbacks, suggesting that they were not well structured. This is exemplified in the following excerpts:

Regarding the feedback, I think, well, at least when I did it, I think the feedback was ineffective, because regarding what the evaluator thought that I failed at, he did not correct me, you understand? It was like “you did this, could have done that”, but I think it would be much more valid if the feedback had been “I think the way you addressed the main complaint could have been deeper into that, you could have done it this way [...]”, suggest, teach, and not just put a mark on a paper, how much you get right, how much will be enough [...] (Intern 1).

I did not find it worthwhile. I think it was a “question and answer” thing, which basically was used by the preceptor to assess whether, according to his judgment, I was insufficient, moderate or good, but for me, regarding the return, it was useless! (Intern 2).

On the other hand, we observed that in the group of residents, the feedback was considered valid, since it generated a review of some points that had been forgotten:

I think it is very valid, this question of the feedback, detailing this type of thing that is sometimes very basic, sometimes very obvious, but that we end up overlooking (Resident 4).

Yes, I think the most worthwhile thing was the feedback at the end, the fact that he pointed out “you should have asked this, you should have done that”. I think the feedback was very valid (Resident 3).

According to the preceptors’ speech, the importance given to feedback is also emphasized, leading the student to seek knowledge that he/she had not previously acquired.

The feedback was highly praised, the interns like it, the residents also do, [...] it is an opportunity for you to see that sometimes you are not providing the feedback. [...] That kind of formalizes and standardizes what you should remember (Preceptor 2).

Some of the people to which I applied it, I noticed a search movement, in the sense of “I took the first Mini-CEX and I realized that I failed in this sense, I forgot this aspect and did not do it. I went back to the book and I reviewed it. When I take the second Mini-CEX, I need to correct this”; I found this very interesting [...] (Preceptor 1).

This authors’ understanding is identified in the residents’ interviews, when they refer to the feedback as an instrument that normally results in learning gain and, for this reason, it becomes essential for the students’ growth when they analyze their daily performance.

According to Zeferino et al., learning from feedback requires that the latter be provided in a constructive and positive way, collaborating for the learner to critically reflect on and create an improvement plan in practice. In this sense, the interns reported that they liked the feedback.¹¹ They agree it is the best part of the Mini-CEX instrument, but point out the need for it to be well structured to become effective in learning gain, as seen in the following excerpts, during a reflective proposition about the observed clinical condition or in the improvement guidance, respectively:

I think the best part was the time of the feedback, when he asked: “What would your conduct be? What would your treatment be?”. Because we already know perfectly well how to perform all the data collection [of the anamnesis]. But establishing the conduct, treatment [...] we do not. Because most of the time you have already been handed the conduct, you have received a patient from a resident, or a staff member and you do not think how that conduct could be improved (Intern 6).

The good thing is that they point out: “You have to improve this”. Some faults they pointed out, [...] and over time we get some habits, so it is good to go back, [...] it was very good (Resident 1).

The evaluation feedback [...] is what makes us grow as professionals. We always need that feedback, that is how we find out what our shortcomings are. It is an important assessment. The perception of teaching and learning, I think, I am not really evaluated, actually taking the clinical history, conducting an interview with the patient [...] I am not usually evaluated. So I think it is important to be evaluated at that moment, it helps me to organize my mind and that brings a lot to me. So as I said, it is important for me to evaluate myself as well as for the preceptor to evaluate me (Resident 11).

Giving feedback, according to Zeferino et al., requires skill, understanding the process, creation of a favorable environment and a relationship of trust. It is not possible to inform the students that their diagnostic hypothesis was wrong or that they did not collect all the necessary data during the clinical history without causing a sense of disappointment or frustration. On the other hand, this information is essential and cannot be omitted¹¹.

Bohnacker-Bruce carried out an interesting study from the point of view of the students’ satisfaction and engagement, with feedback. They conclude that the assessed students directly relate to individual feedback, although a minority of them has this opportunity¹².

The interns’ interviews support this assertion, as they consider feedback to be an important learning tool and, above all, they reinforce the importance of providing it in an effectively manner:

I think it does not make any sense to undergo a Mini-CEX like this and not have feedback. And then, what? What did I miss? For me, as a student, it is the main part to assess what I did wrong, what I should study about the case, about a conduct [...] (Intern 8).

The feedback was the best part. It literally gives you back things that were perceived in you that are positive and things that you should add at another time. This tends to improve longitudinally (Resident 9).

Feedback is important, even for the personal growth of the person being evaluated, what must be improved, what their failures and their qualities are (Resident 2).

Watling et al. clarify that medical students like both positive and negative feedbacks. However, in the negative comments, they emphasize the importance of these being accompanied by an action plan for improvement¹³.

As suggested by Sargeant et al., the main quality for the student to receive feedback is the capacity to reflect on the self-assessment and self-perception of their performance and develop internal feedback. This condition, for the authors, will facilitate the acceptance of external feedback¹⁴.

About the condition to receive feedback, Borges et al. add that, when only the negative points of the student’s performance are highlighted, a hostile environment is created and, normally, the teacher’s superiority is emphasized, without opening the opportunity for dialogue and then, the teacher’s inhibiting influence is reinforced over the student¹⁵. Feedback, according to the authors, requires interaction between both of them and has as a fundamental point the dialogue without preconceptions, always present in the teaching-learning process.

Strong evidence, identified in the literature and the statements in the interviews, suggest that the quality of feedback has an impact on the students’ learning, perhaps more than any other aspect of the teaching process. Therefore, we perceived that best practices associated with giving and receiving feedback are necessary, just as our interviewees also suggested alternative behaviors.

The quality of the offered feedback, as seen in the interviewees’ speech, significantly interfered with the receptivity and acceptance of the message:

So he gave me feedback, I do not feel like he added at all to my training, you know? But, maybe, if I had taken on a more complicated case, if I had had a little more difficulty, you understand? I think it would have helped (Intern 10).

The way it was applied, I think it was not so relevant, I think it would have to be changed a little [...] (Resident 10).

This improvement of those who apply feedback should be reassessed, [...] which is always a moment that I also find difficult, as sometimes it has to be adapted to the student’s personality or the way that he/she sees the feedback, and sometimes you have to perceive how the reaction is in the first few minutes of the conversation (Preceptor 3).

In another study by Watling et al., the study participants highlighted a higher frequency of vague and non-specific feedback in Medicine, in any learning context, and that feedbacks with such characteristics are depreciated by those who receive them. They suggested that, regarding Medicine, it would be interesting to stipulate challenging tasks with clear goals and subsequent aligned feedbacks¹³.

Borges et al., emphasize that in relation to frequency, good practices regarding formative assessment, they recommend that feedback be offered regularly, in order to offer opportunities for students to reflect and review their practices even during the educational experience and that in addition to being frequent, it must have quality¹⁵.

The need for more frequent feedback was also raised and the moment when it was provided during the internship was also questioned:

Because we spend a whole month there, with the preceptors, and we only receive feedback at the end of the month. So, this is the possibility of having another feedback during this interaction. But in practice, I think that our reasoning becomes a little faster [at the end of the internship] (Resident 6).

The evaluation feedback [...] is what makes us grow as a professional. We always need that feedback, that is how we find out what our flaws are. It is an important evaluation. The perception of teaching and learning, I think, I am not really evaluated, taking a clinical history, conducting an interview with the patient [...] I am not usually evaluated. So I think it is important to be evaluated at that moment, it helps me organize my mind and that brings a lot to me. So as I said, it is important for me to evaluate myself, as well as for the preceptor to evaluate me (Resident 11).

The interviews show us that the students recognize the feedbacks as a tool that allows the improvement and the performance of their conducts, when performing the physical examination and in the clinical skills in general, because as much as possible, when their weaknesses are identified, it contributes to the possibility of alternatives for overcoming them.

Bedside evaluation

Regarding this category, interns and residents reported that they had no experience of bedside evaluation with the preceptor. This evaluation did not happen, frequently due to time.

We had never done this before (Intern 5).

Listening while we talked to the patient, no. We collected the patient history separately and then went over it, but not at the same time (Intern 1).

It was the first time I did something like that at the internship. We had something similar at the basic health unit (Intern 11).

I liked it. I also had no contact with this methodology, [...] because we do not have this type of evaluation in medical school. It is strange to have someone evaluating you (Resident 2).

They are there with you as a partner. We will collect the history together with the patient, because on a daily basis you cannot do that with all patients (Preceptor 4).

Some interns and residents comment that they felt pressured by the presence of the preceptor at the bedside, resulting in a feeling of anxiety that led them to behave differently from the usual way in their daily practice.

Normally, before talking to the patient, I wash my hands. But, knowing that you are being evaluated, and that if you do not wash your hands you will lose points, you end up forgetting it, because it brings you the feeling of the anxiety of the test itself. So I think it is not beneficial for the student [to have] the preceptor at the student’s side during the [...] [collection of] anamnesis (Intern 5).

Because at the time I was much more tense, I forgot what I was going to ask. Sometimes I asked and did not grasp the answer. So, for me, it was really bad this issue of him being there beside me at the time (Intern 2).

Of course, during an evaluation, [...] the person being evaluated feels, like it or not, that “stress”, right? Because it generates all the expectations, anxiety [...]. And the preceptor, when he/she is evaluating, has to realize this fact: whether the person is comfortable or not with the practice. [...] (Resident 9).

I confess that I find it a little strange. I do not know if that is because during my formation I never went through this, but I always think it is a “fake” thing, you know? So I think that, right at the beginning, the patient himself gets a little tense. I went through some situations when he was [...]. The intern tried to do the anamnesis and the patient, several times, started speaking to the intern and turned to me to continue talking, exactly when he was having difficulty getting the patient to “focus”. The intern gets nervous. Even though he knows he will not be graded, he gets tense (Preceptor 1).

The bedside assessment allows the direct observation and the possibility of immediate feedback, adding positive value to the student’s training, since they include the three basic requirements of the assessment: 1. The program content, according to the expected skills, aligned with the practice; 2. Offering feedback to the student during or shortly after the assessment; 3. Using the evaluation as a guide to achieve the desired results¹⁶.

I think this issue of taking it to the bedside is very valid. Because, sometimes, even our anamnesis, our physical examination [...] is approached in a way that [...] it complements something. Sometimes we get very used to our ‘habits’, don’t we? (Resident 5).