An Intervention to Improve Medical Student Perception of Observation and Feedback During an Anesthesiology Clerkship

INTRODUCTION

At a large academic center, medical students complete a 2-week required clerkship in anesthesiology during their third or fourth year of medical school. Emphasis is placed on preoperative workup, intravenous line (IV) placement, basics of airway management, pharmacology, and pain management. Students often work with a new anesthesia team each day because of the large number of providers, subspecialty exposure, and call schedule variability, making the development of an “educational alliance” challenging.¹ On postclerkship surveys administered through the medical school, students were in agreement but not strong agreement that direct observation of and feedback on clinical skills were taking place in all clerkships, including the anesthesiology clerkship. While student ratings of the anesthesiology clerkship were acceptable overall, we noted a slight 2-year trend of decreasing survey responses of “strong agreement” that faculty observation and feedback delivery were taking place.

Observation and feedback are cornerstones of teaching clinical skills, but a disconnect exists between student perception of feedback and efforts made to improve the feedback process.² Boehler et al found students less satisfied with feedback instead of compliment, even though their performance was worse after compliment compared to feedback.³ Quantifying the level of feedback needed to improve the perception of feedback is difficult,^1,3 just as it is difficult to quantify the amount or quality of feedback needed to improve or harm performance.¹ Medical education efforts involving the Objective Structured Assessment of Technical Skills (OSATS),^4,5 the Mini-Clinical Evaluation Exercise (mini-CEX),⁶ and the Direct Observation of Procedural Skills (DOPS)⁷ have had some success in the observation and assessment portion of student performance in clinical or technical skills. However, the ideal feedback delivery vehicle remains an issue.¹

During the anesthesiology clerkship, the educators' role includes teaching the Association of American Medical Colleges Core Entrustable Professional Activities of bag-mask ventilation and IV placement.⁸ The anesthesia team directly observes the performance of these core student skills daily in the operating room and during additional simulation sessions. Students participate in 2-hour simulation sessions for both airway management and IV placement on the first day of the rotation before patient contact. These simulations consist of repeated cycles of demonstration of the skill, observation of student performance, and feedback on performance. Despite the time spent teaching these activities, students were not in strong agreement that observation and feedback were taking place.

Most anesthesiology clerkships at academic centers have similarly structured clinical teaching environments and workflows. Therefore, our institution's experience regarding student perception of observation and feedback despite existing educational efforts is likely generalizable to other anesthesiology departments at large academic centers.¹ Because of institution-wide initiatives to improve observation and feedback, coupled with a slight decrease in clerkship evaluations, we proactively intervened.

Multiple interventions were proposed. One proposal was to use an OSATS-style tool to grade an existing clinical simulation for managing bronchospasm, hypotension, and hypoglycemia.⁴ This simulation was an ungraded exercise that paired 2 to 4 students at a time, rather than assigning the tasks to an individual student. Changing the simulation to an OSATS evaluation would be difficult without additional investments in personnel and time. Another suggestion was to develop an Objective Structured Clinical Examination (OSCE). An OSCE would provide a formal grading exercise that could focus feedback on specific areas or skills. This type of exercise may be more appropriate for procedural skills than a simulation debriefing that tends toward generalizable concepts. However, an OSCE approach would also require a significant increase in time and resources for implementation but could be revisited in coordination with new medical school competency-based initiatives in the future.⁹ Another possible solution was to require daily feedback sessions with faculty, residents, or anesthetists and then to formalize the feedback on a paper evaluation. Multiple providers felt that this solution would be burdensome.

We favored a solution that would facilitate assessment at the bedside and delivery of feedback during or immediately after the skill or action was performed. This thinking led to the development of an IV placement checklist in the framework of the OSATS task-specific checklist but without the global rating portion.^4,5 We hypothesized that student perception would improve with the implementation of a formal IV placement assessment during the anesthesiology clerkship because no formal skill assessment had previously existed.