# Building an implementation framework for directly observed feedback by attending physicians

## TL;DR

This paper explores attitudes toward observed feedback in medical training and identifies concerns and suggestions for implementation.

## Contribution

The study introduces a novel approach to feedback observation in medical education and identifies key concerns and mitigation strategies.

## Key findings

- Most residents and hospitalists felt comfortable with observed feedback exchanges.
- Concerns included relationship dynamics, learning environment impact, and feedback quality.
- Suggestions focused on observer boundaries, participant agency, and feedback integrity.

## Abstract

Effective formative feedback from attending physicians to residents is critical for competency-based medical education. Feedback curricula commonly focus on simulated feedback delivery while actual verbal feedback delivery is unobserved by anyone other than the individuals involved. External observation of feedback has received limited attention as a novel method of improving feedback quality. Despite this, there is no research describing attitudes towards directly observed feedback.

We developed two surveys, one for Internal Medicine residents (IMRs) and one for hospitalists, who specialize in comprehensive care of hospitalized patients, at the University of Washington in Seattle, Washington in 2023. Survey validity evidence was gathered prior to disseminating surveys via a census sampling approach by group email listservs. Quantitative questions were analyzed by dichotomizing Likert responses as neutral/disagree vs. agree. Free text comments were qualitatively analyzed via a general inductive approach until theme sufficiency was reached. Survey development and analysis was conducted using a lens of social cognitive theory.

The response rate was 71% (130/184) and 57% (74/129) for IMRs and hospitalists respectively. Most residents and hospitalists reported feeling comfortable with having a feedback exchange observed (105/129, 81%; 46/72, 64% respectively). Hospitalist and IMR concerns about the implementation of directly observed feedback were categorized into three themes: concerns about the relationship with the faculty observer, negative impact on learning environment, and altered feedback quality. Hospitalist and IMR suggestions for parameters to mitigate the challenges of observed feedback were categorized into three themes: the feedback observer’s relational boundaries, empower participant agency, and preserve feedback integrity.

The thematic concerns expressed by both cohorts relate to social monitoring, either of a projected self-image or to the educational safety of a learner. These themes highlight the fundamental importance of psychological safety in developing a program of directly observed feedback for attending physicians and residents.