Adapting Feedback to Individual Residents: An Examination of Preceptor Challenges and Approaches

Competency-based medical education requires frequent feedback over an extended period of time.^1,2  Unlike the focused feedback provided by music and sports instructors, day-to-day feedback in medicine tends to be more global and less deliberate, as preceptors juggle patient care and teaching commitments.³  Feedback “for” learning, compared with “of” learning, requires that preceptors focus on small changes in performance to improve resident expertise in graduated ways to align with milestones and entrustable professional activities (EPAs).

Helping preceptors individualize feedback has not received much attention. Individualized feedback favorably impacts general clinical, technical, and communication skills, and patient care.^4–7  It requires preceptors to consider the individual resident and his or her unique context. Preceptors report difficulties in guiding residents at performance extremes (those who excel or struggle), and those who lack insight about their work, or who are not receptive to feedback.⁸  With feedback conversations occurring in closed settings with little oversight, strategies that preceptors use with different residents are largely unknown.

The purpose of this qualitative study was to explore challenges that preceptors encounter when working with residents and how they approach and adapt their feedback accordingly.

This study was conducted at a large, Canadian, urban academic teaching hospital. We recruited volunteer physician preceptors from multiple medical and surgical specialties who were interested in participating in a faculty development program that entailed a short presentation on approaches to feedback, followed by feedback simulations and debriefings with skilled facilitators. We created 4 scenarios of resident-patient interactions in which professional actors portrayed residents with the following qualities: highly performing, gaps in insight, overly confident, and emotional distress (box). These scenarios were chosen based on literature suggesting challenges preceptors encounter in these contexts,⁸  with details grounded in our experiences as medical educators.

The simulations were held in 2015 and began with a 2-minute video of a resident (a trained actor) discussing goals of care with a patient with advanced lung cancer who had been admitted to the hospital with an infection. The preceptor had 8 to 10 minutes for a feedback conversation with the resident. The facilitator then debriefed the preceptor about the feedback for 8 to 10 minutes. Preceptor feedback conversations with residents and facilitator debriefing conversations with preceptors were video recorded, and the audio was transcribed verbatim and anonymized.

The research team consisted of experienced medical educators with backgrounds in critical care medicine (A.R., J.G., and J.D.), palliative care (A.R. and J.D.), emergency medicine (A.C. and J.G.), pediatrics (A.C.), and anesthesiology (A.R.), and an education researcher (J.L.). The clinicians on the team developed the scenarios and participated as facilitators. Strategies used to enhance credibility included independent analysis by 2 team members (A.R. and J.L.), with regular meetings to discuss perceptions and potential biases, refine the coding scheme, and consider emerging interpretations⁹  and detailed verbatim quotes.¹⁰ 

The study was approved by the University of Calgary Conjoint Health Research Ethics Board.

Two members of the research team (A.R. and J.L.) analyzed the transcripts to explore how preceptors approached the scenarios. We drew on framework analysis,¹¹  a structured and systematic form of thematic analysis^11,12  that facilitates comparison of large qualitative data sets within and across scenarios, involving familiarization, coding, framework development, indexing, charting, and interpretation (figure 1). Data analysis began by viewing the videos and reading through the transcripts in depth to become familiar with the data. We then coded the transcripts, paying attention to common and unique approaches taken by preceptors. We also noted how residents responded to preceptors and how preceptors responded to facilitators. The coding team met after reviewing every 2 to 5 transcripts to discuss emerging codes and interpretations; discrepancies were resolved through discussion. From the codes, we developed 8 framework categories: setting the agenda, building the relationship, reactions, description, performance analysis, teaching, summarizing, and strategizing. Data from each transcript were indexed to the framework categories, and data within each category were charted.

In the interpretation phase, we examined charted data within and across simulated scenarios, looking for similarities and differences in the challenges encountered and how preceptors approached the residents in the different scenarios. We focused on preceptor-resident data to identify patterns of communication in the feedback conversations, and on facilitator-preceptor data to gain a deeper understanding of preceptor experiences and challenges in interacting with the residents.

The study included 18 preceptors, from medical (15) and surgical (3) specialties. Preceptors had been in clinical practice for a mean of 15 ± 12 years. Data analyzed encompassed 55 video transcripts of preceptor-resident feedback and 56 video transcripts of facilitator-preceptor interactions (the numbers of videos by scenario are shown in the box).

For each scenario, we identified the challenges encountered and the approaches taken by the preceptor, as well as unique challenges and effective approaches that were specific to the context portrayed (as described in the table).

We identified common challenges across all 4 scenarios. Preceptors recognized the need to integrate resident learning with their own goals and develop a shared agenda for feedback.

Nonetheless, preceptors had difficulty finding an appropriate balance between reinforcing what was done well and discussing areas for improvement.

Preceptors struggled to balance the resident perspective with sharing their own perceptions. They wanted to encourage reflection and uncover the rationale behind observed behaviors, while at the same time considering strengths and gaps. Some participants felt the preceptors were overly directive, while others spent the majority of the time asking reflective questions of the resident without adding their own observations.

There were also specific challenges unique to each scenario. For the highly performing residents, preceptors voiced challenges around identifying what to discuss and wanting to help the residents improve, while not necessarily feeling confident that the residents were “experts.”

There was additional uncertainty in how to offer ideas for improvement for a highly performing resident, without that resident thinking he or she had performed poorly.

For the resident with insight gaps, preceptors had difficulty facilitating greater insight or willingness to engage in self-assessment.

There was particular tension around the appropriateness of directive feedback, with hesitance in being direct. Preceptors hoped that reflective questions would elicit resident insight that could then be discussed.

When a resident was overly confident preceptors tried to shift the resident from being defensive to considering other perspectives. This was associated with the tension of approaching disagreement without argument and potential escalation of conflict.

Last, for the emotionally distressed resident, preceptors negotiated how to explore distress and offer support without prying or intruding on personal space.

Preceptors also expressed feeling torn between addressing what they observed and supporting the resident experiencing distress. They felt conflicted about discussing gaps in performance, while not wanting to add to the resident's distress.

Preceptors adopted several similar strategies in each scenario, including establishing rapport with the resident through introductions, a caring attitude, and empathy, along with “the basic assumption that residents are here to do their best, and everyone is smart and intelligent” (Video 19.2). Facilitators and preceptors noted the importance of exploring the resident's perspective to understand observed behaviors and identify gaps for discussion.

Across scenarios, some preceptors maintained flexibility through adapting the content and structure of the feedback conversation to resident needs. Others shared challenges they had encountered in their own clinical experiences as an approach to teaching. There were also specific approaches that preceptors adopted to facilitate effective feedback with the residents in the 4 different contexts.

For the highly performing resident, preceptors began by reinforcing what was done well to reassure the resident.

This approach enabled feedback to be framed as a conversation, aimed at coaching the resident from a good performance to excellence.

Preceptors encouraged residents to reflect on their own strengths and challenges. They offered specific observations to link behaviors to patient responses, guiding them in calibrating their self-awareness and self-assessment skills. The intention was to help residents more consciously apply effective techniques in future situations.

For residents with insight gaps and eagerness to please the preceptor, a more direct approach was beneficial.

Preceptors who asked questions to encourage the residents to identify gaps on their own did not appear to be as effective. This often led to circular conversations, where the preceptor repeatedly reframed the question with the hope of obtaining the desired response.

For the resident who was overly confident, preceptors normalized the challenges of the situation and validated what was done well, maintaining resident self-esteem.

In asking open-ended questions to understand the resident's perspective, preceptors identified points they could agree with and then added their own observations, perspectives, and rationale.

Preceptors asked questions to help this group of residents reflect on how they would feel as the patient so that the resident might consider a more empathic approach. Finally, eliciting resident ideas about strategies to implement some of the teaching points offered by the preceptor avoided disagreement around the teaching point itself.

For the resident who was emotionally distressed, participants followed their intuition that something was amiss and invited them to share their story.

Maintaining an open mind while exploring the source of distress was important, as distress could be related to poor performance or underlying personal issues. Normalizing the situation without minimizing the resident's experience helped create a safe environment for dialogue.

Preceptors sought permission from the resident to defer feedback to a later time, focusing instead on supporting the person sensitively. Compassionate responses included helping the resident identify a support system, and sharing approaches of how the preceptor or colleagues had previously addressed their own distress in clinical work.

Preceptors in this study identified some common feedback challenges across all scenarios as well as challenges unique to different contexts, ones that required adaptation of their approach. Common challenges included developing a shared agenda, navigating degrees of directedness, and balancing discussion around reinforcing and corrective feedback within a short period of time. In addressing these common challenges, preceptors recognized that a supportive relationship was foundational. They established rapport, explored residents' reactions and thoughts, adapted feedback, and shared their own clinical experiences. These approaches are congruent with general recommendations for effective feedback¹³  and consistent with the concept of creating an educational alliance where the resident and preceptor feel safe to share perspectives and experiences.¹⁴ 

We also found that preceptors and facilitators incorporated techniques specific to different residents (figure 2). For the highly performing resident, preceptors adopted a coaching role to help the individual recognize his or her strengths and further refine his or her skills. This involved encouraging reflection on how strengths could be further developed. For the resident with insight gaps, preceptors took a more directive approach to ensure that major performance gaps were addressed and strategies identified to mitigate gaps. In these cases, preceptors had to explicitly describe the gap for the resident to recognize his or her deficits and move the conversation forward to identify ways to address the gaps. For the overly confident resident, preceptors used mediation strategies to encourage residents to transition from defending their actions to reflecting on the patient's experience. This involved listening to the resident's rationale for his or her actions and finding common ground on which to negotiate an alternative approach. Finally, for the emotionally distressed resident, where emotion limited the ability to process performance feedback, a mentorship approach helped the resident identify resources to manage life events. This approach often required abandoning a discussion about performance in order to support the distressed resident. These approaches of coaching,¹⁵  directing,¹⁶  mediating,^17,18  and mentoring¹⁹  have demonstrated effectiveness in other contexts.

Our research has implications for faculty development. While general feedback skills remain foundational, we believe that presenting preceptors with common feedback challenges creates an opportunity to consider how to approach and adapt feedback under variable conditions. Further, this type of interactive learning may help preceptors enhance their effectiveness in competency-based education, where more frequent feedback to enhance resident skills is needed to facilitate progression along milestones and entrustable professional activities. Future research might evaluate the utility of this approach in faculty development and the extent to which skills are transferred to the workplace. We plan to follow preceptors who have engaged in simulations to identify how they have integrated these experiences into their work with residents in the clinical setting.

Our findings are limited by situating the study in 1 Canadian center with volunteer preceptors who focused on feedback around communication skills, and the data may not generalize to all feedback contexts and challenges. There were a limited number of resident scenarios, although the scenarios chosen were common and reflect those encountered in clinical medicine.⁸  Our findings were shaped by the relatively short period of time allocated for feedback; however, this is similar to the timing available for feedback in simulated and clinical settings. Finally, in some qualitative studies, data collection continues to saturation. Our data set was finite, and saturation may not have been achieved.

In this study, preceptors expressed similar challenges in feedback conversations, including developing a shared agenda, navigating the degree of directedness, and balancing reinforcing and corrective feedback within a short period of time. Preceptors applied coaching, directing, mediating, and mentoring strategies to adapt their feedback to the specific needs of individual residents.