53 Collecting patient feedback on trainee skills Dialogical space No facilitated dialogical space was provided within the study period, yet one resident took the initiative to discuss the received patient feedback in a formal assessment with a supervisor. The others admitted that they only reflected on patient feedback by themselves. During interviews, residents did reflect on questionnaire results. Five residents considered positive feedback encouraging, and all were able to recapitulate specific positive feedback points. Positive feedback was valued important. It contributes to a positive self-image. Negative feedback, however, seemed to trigger individual reflections to a larger extent, with five residents elaborating on negative feedback points in particular. As one resident said: “What sticks the most are the outliers (…) People who say: I really did not like it. I found her a bad doctor, because (…) she only came up with numbers and did not listen to me as a patient.” A second described the internal dialogue that was triggered by the negative feedback: “… and I was thinking: (…) Do I recognize myself in this feedback? (…) And then I thought: No, I do not.” Discussion and Conclusion Discussion In this mixed methods pilot study, it was quantitatively tested whether a structured patient feedback intervention would enhance residents’ SDM skills. In addition, we qualitatively explored residents’ views about SDM and the potential usefulness of patient feedback in their skills development. Residents considered SDM to be the new standard in healthcare and felt great responsibility for correct SDM performance. Interview results also indicated that residents generally valued patient feedback and that they were able to reflect-upon-action. It is questionable, though, whether patient feedback played a big role in these reflections, as only four residents could formulate specific learning points based on this feedback. These results are reflected in the questionnaire scores as well, as no differences were found between individual residents or between group scores over time. The lack of change might have other causes than ineffective patient feedback, though, as numerous other dominant forces were identified, such as guidelines and supervisors lacking SDM guidance. These forces did not change throughout the study period, and therefore, resident performance might have largely remained the same. Furthermore, questionnaire results could have been influenced by other factors, such as low response rates, timing of the invitational email, and the non-normal distribution of questionnaire results. In fact, questionnaire scores showed a distinct ceiling effect, [24] with residents mainly scoring within the top 25% scoring range. These generally high scores might even have decreased the urgency for behavioral change. Moreover, it would be inaccurate to conclude from the questionnaire results alone that patient feedback did not improve reflexive practice. Using patient ratings to evaluate physician performance has produced varying and opposing results in the past anyway. [25] It seems hard to measure clinical performance with a questionnaire due to a lack of precise definitions of the skills measured and the unresponsiveness of assessing instruments. [25] 3
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