Feedback in Pakistan’s Medical & Dental Education System

Kashif Hafeez¹                                              BDS, MFDRCSI, FFDRCSI, FDSRCSEd

Aiyesha Wahaj²                                            BDS

INTRODUCTION

Feedback refers to the return of information about any related concurrent system or process which tends to produce an effect pertaining to the regulation or consecutive optimization of performance. Altogether it forms a complementary relevant and meaningful interaction between learner and the system^1,[1]. It should be both interactive and reinforcing as it guides the learner’s future performance.

ESSENTIAL COMPONENTS OF EDUCATIONAL FEEDBACK:^1,2,3.

Following are the components of feedback mechanism:

1. Feedback should be undertaken with a common goal in mind by the trainer and the trainee
2. It should be well timed and planned.
3. It should be based on first hand data.
4. It should be regulated in quantity and limited to behaviors that are remediable.
5. It should deal with specific performance, not generalizations.
6. It should deal with decisions and actions, rather than assumed intentions.

Feedback is interpreted as a staged comprehensive system between the learner, tutor and the institution. All aimed for one thing, to keep balance between the ongoing education processes. Feedback also helps to identify the learning problems in a supportive way. It constitutes the opinions, ideas and suggestions from all the entities which are considered to be essential parts of a learning system. In contrary to the standard our ongoing education system concentrates less on building effective feedback process. The students have limited access to the whole process. There is a lack of coordination both at the level of learner and the instructor. As a result, there is consistent deficit of professional knowledge development and its sharing. Feedback requires integration of opinions about educational process taken from learner, teacher and the institution. Later on the collected information is presented in a format and its result is to be interpreted as positive or negative in building efficient educational system.

POSSIBLE OUTCOMES ASSOCIATED WITH MEDICAL EDUCATIONAL FEEDBACK PROCESS

Following are the possible outcomes related to feedback system .They may be interpreted both in positive and negative format^4,5,6,7,8.

1. As an effective means of improving professional medical skills.
2. As a fundamental component of advance continuing professional education medical practice.
3. Goals may set upon precise standardization.
4. Unskilled environment may read it as personal judgment.
5. May find to be as time consuming.
6. Not consistent method due to lack of proper collection of data output.

The figure 1; shows the steps how feedback interlinks and improves the outcome of medical educational process if employed in an effective manner. It impacts the professional standard of an institution and also helps to build the reform plans which prioritize patient safety with advance clinical professional practice.

FEEDBACK CRITERIA FOR ENHANCING PROFESSIONAL MEDICAL EDUCATION

Feedback acts to enhance educational system ability to transform itself into a productive system .The feedback can be in both documented and electronic format. Professional regulatory bodies evaluate feedback exclusively as an ongoing process^7,8,9. The comprehensive stages through licensure, verification, data accountability and change in performance through these means favor the future recognized change in terms of both supervision and professional learning. Both tutors and students share benefits equally which include comprehensive understanding of required curriculum with evidence based practice. Medical educational constitutional policy must carry both educational development plans and all other contributory data,  evaluate it in different steps to check its timely progress .This process should be effective in all regions of the country7,8,9,10,11,12,13.

STAGED STANDARDIZATION IN EDUCATIONAL FEEDBACK SYSTEM:^12,13.

The staged standardization provides effective means to integrate advance professional education into the current education system. During the process, effectiveness is periodically assessed upon the feedback provided by both the learner and the institution. Following staged standardization components need to be assessed:

1. Teachers assessment based upon licensure.
2. Need to enhance or upgrade through annual certificationor recertification process.
3. Advanced professional development sessions.4. Practice evaluation based upon set standards and monitoring.
4. Teacher student interactions and assessment throughPerforma’s or electronic questionnaires.
5. Constant monitoring of professional developmentthrough evidence based practice.

BASIC STEPS FOR TRAINERS

Davidoff and Berg(1990), has suggested four basic steps for trainers in this process. The steps are as follows:¹⁴.

1. Plan,
2. Teach/act,
3. Observe and
4. Reflect

Supervision is the critical part of an educational system. It provides the learner an appropriate way to explore its expertise with basic standards of care towards their patients or living environment. It constitutes one of the building blocks of an institution. Any institution without proper supervision and standards, lack its basic ability to benefit the entire educational system. There are lots of other proponents but the learner needs supervision primarily. Every institution has its own set standardized criteria towards any subject or process. This can never be generalized in subjective manner until the data of proper feedback is studied¹⁵.

PENDLETON METHOD OF FEEDBACK

A common model for giving feedback in clinical education settings was developed by Pendleton (1984)¹⁶. It includes basic rules which encompasses objectives both from trainer and learner perspective. The method is as follows:

1. Check, learner wants the feedback and is ready for it
2. Let the learner give comments/background to the material that is being assessed.
3. The learner states what was done well.
4. The learner states what could be improved.
5. The observer(s) state how it could be improved.JPDA
6. An action plan for improvement is made.These rules explain the feedback system from the beginning and give the charge back to the learner. This can be utilized in short feedback sessions or for detailed long sessions.

FEEDBACK FOR GROUPS

When providing feedback for groups, an interactive session is very beneficial. This states to develop a comprehensive statement or interaction between the learners and the educator. The process essentially is constructed upon the learners own self-assessment, it should be detailed and collaborative, it help learners to take responsibility for their own learning needs. A structured approach requires the need that both the trainees and trainer must target what is expected of them during the feedback sessions. The salient points for giving feedback to groups are as follows¹⁵. .  Initiate .with the agenda of the trainees .  Target the outcomes what the session of discussion is trying to achieve.

.  Encourage the trainees to do self assessment and come up with problem solving firstly.

.  Interact with the whole group for problem solving.

.  Feedback should be detailed and descriptive.

.  Feedback should include, what has worked previously and what can be done in the future.

. Alternatives should be suggested.

. Solutions should be rehearsed to gain confidence

. Supportive attitude should be adopted.

. The whole group learns from this interactive session.

. Concepts, principles and research evidence should be quoted as and when needed.

. In the end, a structured plan and summary should be discussed.

COMPARATIVE PROFESSIONAL MEDICAL EDUCATION ASSESMENT

Our professional medical & dental educational system need strategic staged evaluation which is found to be essential worldwide. Professional educational criteria needs uniform standardization through core to layer. Optimization of proper feedback in every institution needs to be established. Comprehensive assessment through various means to effectively check professional competency is required. Medical educational policy needs to be established which evaluates data construction and its continuous upgrading at various professional educational levels. Professional educational system from primary till advance professional level must comprise of staged developmental sessions both for students and teachers. The only process which keeps the learner and the tutor interlinked is feedback communication between them. Educational criteria at all levels and their proof evaluation are required to assess the required progress in this regard. Process of decision making needs to be evaluated. Uniform constitutional data required to be set to analyze educational system from both student and teacher perspective so that it provides balanced productive results at professional evidence based practice.

POSSIBLE LIMITATIONS

The following are the basic possible limitations in implication of both interactive and reinforcing feedback process in professional medical education:^17,18.

1. Unsupported educational frame work
2. Concerns about resulting consequence
3. Time limit
4. Unprofessional clinical skills
5. Lack of knowledge about particular medical educational system.
6. Lack of evidence based clinical practice

RECOMMENDATIONS

Feedback sessions should be made mandatory during the training years and these sessions should form the basis of trainee’s career progression. Every institution in their constitution should emphasize the importance of learner’s led feedback. Tutors should realize that this is an opportunity for the trainees to reflect upon them and suggest what is beneficial for them.  A sense of confidence building is felt when trainer talks about the positives of the trainee’s progress. During the session the pre discussion summary allows to remember the key points. The session should be learner lead so trainee should realize that he is involved in all stages of the session. Problem solving should be done by the trainee; it reinforces the ownership of the problem. The trainee should formulate the future course of action that will augment his commitment and agreement to the future plans.

Continuation of the learning process should been forced in the end.

REFERENCES

1. Sachdeva A. Use of effective feedback to facilitate adult learning/ Journal of Cancer Education 1996;11:106118.
2. Salermo et al. Faculty development seminars based on the one minute preceptor improve feedback in the ambulatory setting. JGIM 2002;17:779-787.
3. Jack Ende, Feedback in clinical medical education. J Am Med Assoc.1983;250:777-781.
4. Hewson M et al. Giving feedback in medical education: verification of recommended techniques. JGIM 1998;13: 111-116.
5. Gil et al. Perceptions of medical school faculty members and students on clinical clerkship feedback. J Med Educ. 1984;59:856 – 864.
6. Irby et al. Factors affecting ratings of clinical teachers by medical students and residents J Med Educ 1987;55: 1-7.
7. Isaacson JH et al Resident Perceptions of the evaluation process. Society of General Internal Medicine. J Gen Intern Med 1995;10(suppl):89.
8. Eichna LW: Medical-school education, 1975- 1979: A student’s perspective. N Engl J Med 1980;303:727734.
9. Nadler DA: Feedback and Organization Development: Using Data-Based Methods. Reading,Mass, AddisonWesley Pub Co Inc, 1977.
10. Hyman RT: Improving Discussion Leadership. NewYork, Teachers College Press, 1980.
11. American Board of Internal Medicine, Benson JA Jr,Bollet AJ, Faber SJ, et al: Clinical Competence in Internal Medicine. Ann Intern Med 1979;90:402-411.
12. Klein RH, Babineau R: Evaluating the competence of trainees: It’s nothing personal. Am J Psychiatry 1974;131:788-791.
13. Beer M: Performance appraisal: Dilemmas and possibilities. Organizational Dynamics, 1981, winter, pp 24-36.
14. Davidoff, S., Berg, O.V.D. (1990) changing your teaching: the challenge of the classroom: Centaur publications.
15. Kilminster, S., Cottrell, D., Grant, J., Jolly, B. (2007). Effective educational and clinical supervision. Med Teach. 20079;29:2-19.
16. Pendleton D, Schofield T, Tate P & Havelock P; The Consultation: An Approach to Learning and Teaching: Oxford: OUP. 1984.
17. Sadler, D.R. Beyond feedback: Developing student capability in complex appraisal.Assessment & Evaluation in Higher Education.2010; 35: 535-550.
18. Orsmond, P., S. Merry, and K. Reiling. Biology students ‘utilization of tutors’formative feedback: A qualitative interview study. Assessment & Evaluation in Higher Education.2005; 30: 369-386.

1. Post graduate Orthodontic Fellowship Resident. Dr .Ishrat -ul- Ebad khan Institute of Oral Health Sciences.Karachi, Pakistan.  < aiyshwj@gmail.com >

Corresponding author: “Dr Kashif Hafeez ” < hafeezkashif@yahoo.co.uk >