Preceptor Feedback Research Articles

TF1 A Tool for Faculty Preceptors to Guide Emergency Departments Learners in Constructing Focused Assessments of Common Presenting Complaints

Patient management in the emergency department (ED) requires rapid evaluation and stabilization, efficient data collection, and timely risk stratification of life-threatening conditions. Heuristic models for thinking (eg, the ABCDE approach to trauma) are required to efficiently make decisions to resuscitate patients and narrow lists of differential diagnoses. Constructing and practicing such models of thinking is important in the development of the emergency medicine (EM) physician. Instructional modalities that encourage learners to develop systematic approaches to patient presentations, such as simulation, should be used early in their EM education. The goal of this project is to provide faculty preceptors in the ED with a tool to better support students and interns construct focused patient assessments for common presenting complaints. Primary: Provide structured evaluation of ED learners’ assessments of patients with common chief complaints. Secondary: In regards to common ED chief complaints, learners will list critical differential diagnoses, list necessary history and exam items to evaluate such diagnoses, complete a focused history and physical exam, and synthesize history and exam findings to formulate appropriate assessments and plans. “Chest pain” was selected as the chief complaint for an initial tool. A checklist was formed in table format, with rows consisting of history of present illness, review of systems, past and family medical history, and physical exam. Columns consisted of six critical diagnoses for chest pain: myocardial infarction, pulmonary embolism, aortic dissection, pneumothorax, cardiac tamponade, and esophagitis. Cells were populated with relevant history and exam findings, each with empty positive and negative checkboxes. A learner will evaluate an ED patient with chest pain and present to a faculty preceptor. The preceptor will use the checklist to document the learner’s positive and negative history and exam findings. The preceptor will provide feedback regarding the learner’s consideration of the critical differential diagnoses, what history and exam items are still required to complete an evaluation for these diagnoses, and whether the learner’s history and exam findings justify their assessment and plan. Learners are encouraged to re-examine the patient to complete the checklist, and discuss with the preceptor their additional findings and if and how their assessments and plans would change. The primary objective can be measured by asking preceptors if the tool helped them provide more structured feedback to learners and by asking learners to rate the quality of preceptor feedback. Secondary objectives can be measured by tracking learner checklist completion for subsequent assessments of ED chest pain patients or via preceptor evaluations of learners’ assessments over time, particularly whether they consider all critical diagnoses and demonstrate the ability to synthesize history and exam findings into an appropriate assessment and plan. This tool can be an effective adjunct in evaluating new learners' assessments of common ED chief complaints. This method provides more structured feedback from which learners are encouraged to develop their own systematic approaches to common patient presentations.

Integrating teaching into routine outpatient care: The design and evaluation of an ambulatory training concept (HeiSA).

Background: Direct patient contact is crucial in learning important interactional and examination skills. However, medical students have limited opportunity to self-responsibly practise these skills in authentic clinical settings and typically receive insufficient feedback on their performance. We developed a novel single-session ambulatory teaching concept (Heidelberg Student Ambulatory training, “HeiSA”) to prepare students more adequately for clinical-practical responsibilities.Methods: To identify challenges and target group needs, we reviewed current literature and consulted an expert group of faculty lecturers and training researchers. The resulting course concept was put into practice at the University Hospital’s general-internistic outpatient department and evaluated in a pilot phase (winter term 2010, ten participants) and a main project phase (summer and winter terms 2011, 14 and 21 participants, respectively). Third and fourth-year students autonomously take a new patient’s medical history and conduct a complete physical examination in one hour under supervision, followed by extensive preceptor feedback. To assess learning achievements, participants and a control group self-rated their communication and examination skills before and (participants only) after the session on six-point Likert scales (1=completely able, 6=completely unable). The preceptor also evaluated the participants’ performance. Finally, all stakeholders re-evaluated the course concept.Results: HeiSA is a feasible training concept and accepted by staff members and students. It provides opportunities to practise clinical skills in a relevant, authentic learning environment with extensive feedback. Participants report improved anamnesis (0.27±0.51, p=.003) and physical examination (0.25±0.41, p=.008) skills. The preceptor evaluated students’ performance to be generally high, with ratings ranging from 1.40±0.55 (item: the student does not interrupt the patient) to 2.51±0.89 (item: psychosocial anamnesis). Conclusions: HeiSA is a viable course concept for teaching anamnesis and physical examination skills. It integrates student teaching into routine care and can potentially be adapted to other outpatient departments.

Progressive Dosing of Observed Real-Life Clinical Exposure for Nurse Practitioner Training.

In most advanced practice programs, preceptors are relied on for providing student clinical experiences. Preceptor feedback often indicates that many students show competency deficits in well child care, case presentation, and clinical skills. An innovative preclinical experience was developed using nonscripted pediatric patient and family volunteers from the local community. During the three 4-hour experiences, students obtained a health history, performed a full physical examination, and presented their findings using a standardized case presentation format. Student anxiety and levels of confidence were assessed before and after each experience. Student anxiety decreased, and self-confidence and clinical skill competencies improved. Students who participated in the experiences with faculty demonstrated improved entry-level competencies, compared with previous cohorts who had not received the intervention. Preclinical experiences using pediatric patients improved advanced practice nursing student confidence and competencies and reduced anxiety, improving overall entry-level clinical performance. [J Nurs Educ. 2017;56(9):552-555.].

Content and conceptual frameworks of psychology and social work preceptor feedback related to the educational requests of family medicine residents

ObjectivesSupervision of communication competency in clinical settings in medicine is an important component of professional training. The purpose of this study was to describe the content and rationale of psychology and social work preceptor feedback to family medicine residents who express educational needs during case-based written vignettes. MethodsWe conducted a qualitative study with 25 psychology and social work preceptors from family medicine departments of the three French-speaking universities in the province of Quebec, Canada. During an individual interview, preceptors were asked to respond to three short case-based written vignettes depicting resident educational issues regarding communication and to explain their responses. Authors analyzed the content of responses and the conceptual frameworks reported. ResultsThe three vignettes elicited 475 responses, including 58 distinct responses and 33 distinct conceptual frameworks. Therapeutic alliance and stages of grief were the two most reported conceptual frameworks. ConclusionThe vignettes stimulated a wealth of responses and conceptual frameworks among psychology and social work preceptors in family medicine. Practical implicationsThe complete list of responses could be useful for faculty development activities by stimulating preceptors’ reflexive practice with regard to their responses, the educational goals of these responses and the conceptual frameworks underlying their feedback.

An autoethnographic exploration of the use of goal oriented feedback to enhance brief clinical teaching encounters.

Supervision in the outpatient context is increasingly in the form of single day interactions between students and preceptors. This creates difficulties for effective feedback, which often depends on a strong relationship of trust between preceptor and student. Building on feedback theories focusing on the relational and dialogic aspects of feedback, this study explored the use of goal-oriented feedback in brief encounters with learners. This study used autoethnography to explore one preceptor's feedback interactions over an eight-month period both in the ambulatory setting and on the wards. Data included written narrative reflections on feedback interactions with twenty-three learners informed by discussions with colleagues and repeated reading of feedback literature. Thematic and narrative analyses of data were performed iteratively. Data analysis emphasized four recurrent themes. (1) Goal discussions were most effective when initiated early and integrated throughout the learning experience. (2) Both learner and preceptor goals were multiple and varied, and feedback needed to reflect this complexity. (3) Negotiation or co-construction of goals was important when considering the focus of feedback discussions in order to create safer, more effective interactions. (4) Goal oriented interactions offer potential benefits to the learner and preceptor. Goal oriented feedback promotes dialogue as it requires both preceptor and learner to acknowledge and negotiate learning goals throughout their interaction. In doing so, feedback becomes an explicit component of the preceptor-learner relationship. This enhances feedback interactions even in relatively brief encounters, and may begin an early educational alliance that can be elaborated with longer interactions.

Using Simulation in a Psychiatric Mental Health Nurse Practitioner Doctoral Program.

The use and effectiveness of simulation with standardized patients in undergraduate and graduate nursing education programs is well documented. Simulation has been primarily used to develop health assessment skills. Evidence supports using simulation and standardized patients in psychiatric-mental health nurse practitioner (PMHNP) programs is useful in developing psychosocial assessment skills. These interactions provide individualized and instantaneous clinical feedback to the student from faculty, peers, and standardized patients. Incorporating simulation into advanced practice psychiatric-mental health nursing curriculum allows students to develop the necessary requisite skills and principles needed to safely and effectively provide care to patients. There are no documented standardized processes for using simulation throughout a doctor of nursing practice PMHNP curriculum. The purpose of this article is to describe a framework for using simulation with standardized patients in a PMHNP curriculum. Students report high levels of satisfaction with the simulation experience and believe that they are more prepared for clinical rotations. Faculty feedback indicates that simulated clinical scenarios are a method to ensure that each student experiences demonstrate a minimum standard of competency ahead of clinical rotations with live patients. Initial preceptor feedback indicates that students are more prepared for clinical practice and function more independently than students that did not experience this standardized clinical simulation framework.

Aid to Our Front Line Warriors: A Brief End-of-Life Communication Curriculum for Internal Medicine Interns (S770)

•Describe the components of a brief end-of-life communication skills training curriculum.•Recognize the benefit of a brief communication training session using a multimodal teaching approach including didactic, simulation and feedback. Internal medicine interns (interns) are the physicians spending the most time with hospitalized patients, frequently assisting with end-of-life (EOL) decision-making. However, most report feeling ill-equipped for these situations. Multimodality hands-on training, including didactics, practice and feedback, have been effective in improving skills/ confidence in EOL communication. To assess a brief hands-on EOL communication curriculum for interns (PC-I). Interns (n=24) participated in PC-I comprised of a one-hour didactic, a one-hour role play, and two observed structured clinical encounters: Breaking Bad News (BBN), Family Meeting (FM) with real-time evaluation (skills checklist/ written comments), and preceptor feedback. Self-Efficacy in Palliative Care (PC) Communication sub-section (SPEC-C) evaluated pre/post curriculum self-assessment of competence. Participants provided subjective post-curriculum impressions. 45.8% had no prior PC training. BBN and FM checklist mean score was 32.2 /45 (Min 18, Max 41, SD 4.67), and 26.6 /39 (Min 15, Max 38, SD 6.12), respectively. Checklist-identified improvement themes: 1) introducing PC; 2) assessing patient/family desire for prognostic knowledge; 3) exploring patient/family emotional state; and 4) summarizing discussion. Preceptor feedback identified four improvement themes: 1) setting meeting agenda “warning-shot”; 2) avoiding medical jargon; 3) discussing prognosis; 4) appropriate utilization of surrogate decision-maker. Intern impressions identified four major themes: 1) safe environment for skills practice; 2) confidence to perform skills in clinical setting; 3) valued feedback; 4) patients/families appreciate direct conversations about death/dying and prognosis. SPEC-C showed improvement in self-perceived confidence discussing patient’s death with patient (p<0.05), with family (p=0.07), with family during bereavement (p<0.05). A brief, hands-on, multimodality EOL communication curriculum is a valuable learning experience for interns at early stages of their career, which can improve confidence and identify specific areas for continued skill development.

Clinician's Commentary on Anderson et al.(1.).

Clinical education is a vital element of training for physical therapy (PT) students, providing opportunities to integrate theory learned in the classroom with the realities of clinical practice as well as for professional socialization and growth.2 However, the role of educator poses challenges for clinicians, and finding adequate capacity for students in clinical settings can be problematic; busy clinical caseloads with increasingly high-acuity patients and a focus on rapid discharge reduce the time clinicians have to spend with students, and in the private sector time taken away from direct patient care can also mean loss of income.2,3 Placement requirements such as formal student evaluations should not deter clinicians from taking on students by making excessive demands on their time; evaluation tools must be user friendly for educators, must measure student performance in a valid and reliable way, and must be applicable to client populations ranging from neonates to the frail elderly. The challenge of developing an appropriate tool for this purpose is not limited to the Canadian context; in Australia, for example, the Assessment of Physiotherapy Practice Instrument (APP) was recently developed to address similar issues to those experienced by Canadian clinicians: lack of time; the need for a competency-based, reliable, and valid tool; and the need for a format that is more universally used and accepted.4(p.5–56) Anderson and colleagues address three important elements of creating a new clinical evaluation tool for Canadian PT students: the rating scale, the format for the new tool, and training in the use of the tool.1 Their article is timely: development of a new Canadian evaluation tool is well underway, and a pilot study has just been completed. While the US-based Physical Therapist Clinical Performance Instrument (PT-CPI)5 has been considered the “gold standard” evaluation tool for students completing clinical placements in most Canadian PT programmes for more than a decade, clinical and academic educators' growing dissatisfaction with the PT-CPI has prompted the development of a new tool more closely aligned with Canadian needs. The three criteria examined by Anderson and colleagues are key areas of tool development. First, the format must be applicable for clinicians in a wide range of clinical settings, from tertiary critical-care centres in urban contexts to rural locations in both Canada and developing nations, where Internet access may be unreliable. Second, the rating scale needs to be clear, easily understood, and informative for both clinicians and students. I have observed that many clinical educators (CEs) are confused about the visual analogue scale (VAS) used in the CPI, ranking the majority of students as “near entry-level” for most competencies, even on junior placements. The scale's two anchors—“novice clinical performance” and “entry-level performance”—provide little guidance for clinicians;6 without adequate cues, CEs may instinctively mark a “passing” student at the far right of the scale, regardless of whether or not that “pass” represents entry-level performance. CEs, particularly those with years of experience, may also have a hard time identifying what basic entry-level performance actually is and may therefore rely to some degree on “gut feel,”7,8 compounding inaccurate or inconsistent performance measurement. Thirdly, training for use of evaluation tools must be easily accessible and address the competing demands on clinicians' time; a newer and possibly more acceptable version of the PT-CPI has not been implemented in Canada, partly because of the lengthy orientation requirement for CEs. One aspect of tool development not addressed by Anderson and colleagues is the student perspective. For students, clinical education courses are high stakes, not only because a failed placement can have serious consequences for their academic progression but because students often perceive clinical placements as “where real learning occurs.” Evaluation tools therefore need to be “educationally informative”9 as well as providing a valid rating of competence, and in most programmes the tool is used for formative feedback during placements as well as for summative feedback at the end. The recent pilot study of the draft of the new Canadian tool included both student and preceptor feedback, and it will be interesting to compare and contrast the differing perspectives on the tool from both clinicians' and students' perspectives.

Integrating Medical Students’ Goals, Self-Assessment and Preceptor Feedback in an Ambulatory Clerkship

Background: Self-assessment and feedback are important elements for improving performance. However, coordinating their content remains elusive. Purpose: The purpose is to determine whether student self-assessment and preceptor feedback correlate with course outcomes and whether preceptor feedback informs student self-assessment. Methods: Our students generate initial and midterm goals and preceptors provide midterm feedback. We coded goals and feedback as clinical subsets, knowledge, career oriented, and attitudinal. We assessed associations with exams and evaluations using correlations, chi-square, and comparisons of means. Results: Students usually listed clinical goals (72%), whereas preceptors noted attitudes (50%). Students’ self-assessments had little association with exams, evaluations, or preceptor feedback. Students cited by preceptors for clinical strengths scored higher on exams (77.2 vs. 72.7, p < .01). Those cited for knowledge received more honors and high pass (78 vs. 60%, p = .05) evaluations. Conclusions: Students and preceptors emphasize different aspects of performance. Student self-assessments were not associated with outcomes, but preceptor feedback was. Student self-assessment seemed resistant to feedback.

Using Online Instruction and Virtual Laboratories to Teach Hemostasis in a Medical Laboratory Science Program

Hemostasis laboratory testing methods have changed significantly over the past decades, from totally manual, to fully automated methodologies. Most medical laboratory educators prefer to use manual or semiautomated methods to teach hemostasis so that students can "see" what is occurring during the testing method, but many semi-automated instruments are no longer commercially available or are not cost-effective for education programs. In consideration of these factors and due to programmatic expansion to a coordinate campus, the CLS program explored new ways to teach hemostasis methods equitably and affordably across two distant locations. Working with an instructional design team versed in online education, five virtual hemostasis laboratory exercises were created that mimic the manual methodologies. Web-based didactic instruction was also developed to teach the testing theory and pathophysiology related to patient results. The efficacy of the virtual instruction was evaluated through assessment of student performance on exam questions, professional certification scores for the platelet/hemostasis sub-category, student satisfaction surveys, and evaluation of student performance during their clinical experience. Results showed that students in the virtual delivery format performed significantly better on exam questions compared to the traditional delivery method group, but there was no significant difference in their performance on the professional certification exam. Both student and preceptor feedback have been positive on the value of the exercises for students' understanding of hemostasis.

Content and Conceptual Frameworks of Preceptor Feedback Related to Residents’ Educational Needs

The development of clinical expertise depends not only on frequent practice opportunities but also on receiving quality feedback, especially regarding difficult aspects of learning. The purpose of this study was to investigate the content and conceptual frameworks of preceptor feedback to residents during case presentations. The authors conducted a qualitative and correlational study in which 25 clinical preceptors from one Canadian medical school's internal medicine and family medicine residency programs responded to six written, case-based vignettes depicting residents seeking help regarding a variety of educational issues. Preceptors were asked probing follow-up questions about their responses. The authors analyzed response content, conceptual frameworks used in formulating responses, and the correlation between the two. Overall, the preceptors generated 806 responses, representing 96 distinct topics. The five topics mentioned most frequently related to reading suggestions, leading diagnosis, contrasting clinical findings, patient follow-up, and resident's concerns/feelings about the case. Seventy-three percent of the topics were specific to one or two vignettes. The preceptors used 18 distinct conceptual frameworks in formulating responses (e.g., analytical versus nonanalytical reasoning, problem representation, therapeutic alliance, patient-centered approach). Use of conceptual frameworks was positively associated with greater diversity of responses (r = 0.43, P = .03). The vignettes stimulated rich and extensive lists of topics and conceptual frameworks. These findings represent but one step in the exploration of the content and conceptual frameworks of preceptor feedback and of the interrelatedness of feedback content and process, which have important implications for teaching and faculty development.

Case Western Reserve University School of Medicine and Cleveland Clinic

Case Western Reserve University School of Medicine and Cleveland Clinic

The Palliative Care Clinical Evaluation Exercise (CEX): An Experience-Based Intervention for Teaching End-of-Life Communication Skills

To pilot test the "Palliative Care Clinical Evaluation Exercise (CEX)," a new experience-based intervention to teach communication skills in giving bad news and discussing code status. The intervention allows faculty to observe, evaluate, and give feedback to housestaff in their discussions with patients and families. In 2002-03, the intervention was piloted among 60 first-year residents in the categorical Internal Medicine Residency Programs at the University of Pittsburgh. The authors collected feasibility measurements at the time of intervention, and interns' attitudes were measured before and one week after intervention and at the end of the intern year. Forty-four residents (73%) completed the intervention. Discussions averaged a total of 49.5 minutes (SD 24.1), divided among 12.7 minutes (SD 7.5) for prediscussion counseling between the resident and faculty observer, 25.6 minutes (SD 16.1) for the resident-patient discussion, and 12.1 minutes (SD 5.7) for postdiscussion feedback. Residents rated the Palliative Care CEX favorably (>3 on a five-point scale) on ease of arranging the exercise, educational value, quality of the experience, effect on their comfort with discussions, importance to their education, and value of preceptor feedback. Self-ratings of communication competence showed improvement one week after the intervention. The Palliative Care CEX is feasible and positively valued by residents. The findings from this initial pilot study support the value of further efforts to refine the intervention, to confirm its feasibility in other settings, and to validate its use as an educational and assessment tool.

Integrating communication training into a required family medicine clerkship.

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity-students' clinical years-to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

An Encounter-Based Analysis of the Nature of Teaching and Learning in a 3rd-Year Medical School Clerkship

Background: Much of medical education has shifted from the hospital to ambulatory settings where each student works with a preceptor. Purpose: Our objectives were to describe the nature of community-based learning and to explore how learning experiences vary by type of health care visit. Methods: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of 3rd-year medical students contributed data on 1 full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age, gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, and preceptor teaching content. Results: Sixty-three students contributed data on 4,083 patient encounters. The majority of visits concerned acute complaints (37.7%) or health maintenance (26.4%). Many encounters involved students conducting the cardiovascular and pulmonary exams (33.2% each); fewer encounters involved neurologic (6.9%), gynecological (4.5%), and genitourinary (2.2%) exams. Students reported being observed performing histories and physical exams in 4% and 6% of encounters respectively. The most common student experiences were performing histories and performing physical exams unobserved during acute visits, which accounted for 65.8% and 52.4% of encounters overall. Conclusions: This system is useful for determining educational content and processes that occur in ambulatory settings. Important differences were found in teaching and learning by type of health care visit. This factor can and should be used when considering how students meet educational objectives in community-based ambulatory settings.

Education Online: A Community Preceptor Computer Network

Background: The Dartmouth Community Preceptor Computer Network (DCPCN) provides community physicians with (a) help in selecting and purchasing hardware; (b) a convenient local-area-network e-mail system; (c) access to traditional library- related resources (e.g., card file, journals, text, MEDLINE); (d) Netscape�, the World Wide Web, and the Office of Generalist Education(OGE) home page (oriented specifically to the preceptors and their students); and (e) a clinical information system that gives referring physicians access to their patients' clinical information at Dartmouth-Hitchcock Medical Center (DHMC). Purpose: As medical education moves to ambulatory and community settings, communication among faculty becomes increasingly important. The OGE of Dartmouth Medical School has designed the DCPCN to (a) improve communications of curriculum to rural teaching sites, (b) enhance quality of community-based teaching experiences, (c) support community-based preceptors in their teaching efforts, and (d) help community preceptors engage more closely with academic medical centers. The purpose of this report is to explain some of the processes that we used to accomplish these goals. Method: We measured the growth of this network by course-director use, access and use of E-mail and clinical records, and community preceptor feedback. After 18 months, over 180 teaching physicians are connected to the network. We have defined and distributed a standardized set of software, provided access to a standard hardware package, defined reasonable customer support pathways, trained doctors and their staff, and provided a consulting resource specifically for this population. Results: The use of the network has grown rapidly. Course directors distribute curriculum to community-based preceptors regularly and rely on the network for student and course evaluation. Students are required to use the network to access medical literature in the community setting. Preceptor E-mail communication and access to computerized patient clinical information has risen substantially. Conclusions: Creation of this network has required collaboration among several departments of Dartmouth College and the DHMC to offer hardware, software, network systems, and computer and network support. The DCPCN has provided important benefits to the learners, course directors, and community preceptors at Dartmouth. This system, because of its ease of implementation and use, will form the foundation for the introduction of additional tools to enhance and support community-based teaching.

A worksheet to structure teaching and learning outpatient internal medicine

The Worksheet for Ambulatory Medicine (WAM) was designed to enhance teaching and learning outpatient general internal medicine. It contains a set of explicit learning objectives, promotes important teaching strategies, and carefully structures educational and patient care activities. WAM may help students by: (1) demonstrating methods for more focused history-taking, physical examination, and case-presentation; (2) increasing preceptor feedback; (3) making performance expectations explicit; (4) facilitating and encouraging self-directed learning and reflective, evidence-based, practice; (5) promoting autonomous evaluation and management of outpatient problems; and (6) demonstrating an approach to evaluating undifferentiated clinical problems. WAM may help teachers by: (1) identifying student learning needs; (2) increasing structure and control of teaching sessions; and (3) helping demonstrate steps in the clinical reasoning process. WAM has been pilot-tested with third- and fourth-year medical students. I...

Modification of residents' behavior by preceptor feedback of patient satisfaction.

The authors tested the effect of preceptor feedback to residents of patients' ratings of perceived art and technical quality of care on residents' subsequent performances. New ambulatory patients were asked to complete questionnaires measuring satisfaction with physician behavior during initial encounters. Sixty-eight residents were evaluated by 424 patients over a six-month period. Continuing residents with the lowest scores were assigned to a feedback or a non-feedback group. Residents in the feedback group were individually shown their mean scores on each item, as well as scores for all residents, and were then advised of physicians' behaviors that could increase patient satisfaction. During a subsequent six-month survey of new patients, scores in the feedback group improved more than those in the non-feedback group in art of care, technical quality, and total patient satisfaction (p less than 0.001).