**4. Discussion**

#### **4.1 Discussion**

In this qualitative study, insights were gathered about both patients' and residents' perspectives regarding patient feedback topics. These insights may direct the development and involvement of patient feedback in PGME.

#### *4.1.1 Feedback topics*

Topics patients wish to provide feedback on, touch elements of the current competency framework of CanMEDS used in PGME. For instance, the communicator

#### *Patient Feedback to Enhance Residents' Learning: A Patient and a Resident Perspective DOI: http://dx.doi.org/10.5772/intechopen.108569*

role (**Table 1**) which includes among others, listening to patients, taking a patient seriously, and taking enough time for patients are topics mentioned by both patients and residents as possible feedback topics [10]. Furthermore, both patients and residents put forward the value of feedback on the physician-patient relationship, including establishing trust, empathy exhibited toward a patient, and the ability to clearly explain medical knowledge and attitude toward the patient. Moreover, these topics were also identified by physicians as areas that could be changed and improved on when receiving feedback from patients making them suitable feedback topics to enhance a resident's learning [24].

In line with current trends in healthcare that put emphasis on shared decisionmaking and patient-centered care, the CanMEDS communicator role clearly describes that residents are ought to provide the best available evidence and support patients in their decision-making [3, 4, 10]. Indeed, patients have stated they would like to provide feedback on their involvement in the medical decision-making process. The fact that none of the residents mentioned shared decision-making or related topics in the questionnaire may be explained by cultural issues and their early phase in the development of professional identity [25].

Indeed, studies so far have either focused on residents' communication or interpersonal skills in light of patient feedback, assuming that patients can only provide feedback on these topics [3, 16, 24, 26, 27]. However, the results of this study have shown otherwise. For instance, patients also mentioned the continuity of care, which involves communication between physicians as well as seeing the same physician each visit, as an important topic to provide feedback on. Indeed, the importance of this subject is recognized in the collaborator role of CanMEDS. This role involves, among others, handing over patients' care safely to other physicians, whereby a sufficient transfer of written or verbal communication is used [10]. Although residents are trained in achieving this role, topics related to the continuity of care were not mentioned altogether. This might be explained by the fact that residents think that this could only be assessed and judged by their peers.

Although this study showed similarities between the desired feedback topics mentioned in both groups, a difference between the groups was found as well. Organizational matters, such as waiting times and the process of making an appointment, are something patients intend to provide feedback on to residents, while the latter wish not to receive feedback on this particular topic. At first glance, it may seem obvious that these topics do not concern a resident as it might not always be his or her responsibility alone. However, when looking at the leader role of CanMEDS (**Table 1**) it could be stated that residents are ought to take responsibility in organizational matters in order to improve healthcare delivery in general, which according to the CanMEDS framework involves management, financial matters and organizational matters (**Table 1**) [10].

Additionally, personal aspects were mentioned by patients to provide feedback on, that is, representativeness, tone of voice or attitude, and kindness. These aspects can be recognized in the CanMEDS role of professional as well as the role of communicator. The role of a professional particularly reflects on society's belief in physician's professionalism, which requires them to commit to their own personal health and well-being. Moreover, physicians are ought to demonstrate accountability toward society [10]. However, residents mentioned personal aspects as an undesired feedback topic. It might be argued that based on the CanMEDS roles as well as their accountability toward the public, residents should accept some feedback on personal aspects [10].

#### *4.1.2 Feedback levels*

The effectiveness of feedback depends on the level of feedback aimed at, and whether the given feedback is indeed similar to the feedback level a recipient wants to receive feedback on [8]. This study has also led to insights into what level patients intend to provide feedback and thereby helps to determine its effectiveness. First of all, patients intend to provide feedback at the task-level, which describes how well a certain task is performed, which is in line with what residents wish to receive feedback at. From the literature, we know that providing corrective feedback at this level enhances learning [8]. Therefore, patients' feedback at the task level might be effective to enhance residents' learning. Patients also intend to provide feedback at the process-level which describes the process needed in order to fulfill certain tasks [8, 9]. Residents wish to receive feedback at this level as well, suggesting patient feedback at this level may enhance residents' learning as well. Moreover, Hattie and Timperley (2007) argue that receiving feedback at this level enhances deeper learning as it is an effective way of shaping one's strategy [8]. Lastly, patients also intend to provide feedback at the self-level, which involves feedback at a personal level and includes statements about a resident, such as feedback on his or her attitude, representativeness, kindness, or tone of voice. However, providing feedback at this level generally contains little task-related information and has too little value of enhancing learning [6]. Indeed, residents in this study did not wish to receive feedback at self-level, suggesting that patients providing feedback at this level might not enhance residents' learning. As expected, feedback provision at the self-regulation level was not identified. This level describes the way residents learn, direct, and have applied previous feedback, something patients are unable to monitor over time.

#### *4.1.3 Effectiveness of patient feedback*

Residents did not wish to receive feedback on the self-level. Kluger and Denisi (2000) have shown that feedback directed on the self-level negatively affects one's performance [28]. If negative feedback is directed at the self-level, one may redirect attention to the self and become distracted from what matters, the task at hand [28]. Besides, it is important to take into account that the effectiveness of feedback might even be more influenced by the way it is delivered. Among others, effective feedback is delivered in an appropriate setting, specific, based on observation, and in nonjudgmental language [29]. Additionally, results have shown that patients who have had positive experiences with residents or physicians had difficulties providing feedback topics. Paternotte et al. (2017) also argued that patients who think positively about their physicians have difficulty reflecting on the consultation at a deeper level and provide feedback for improvement [28]. Others have also shown that these patients are not capable of providing critical feedback and are therefore less crucial to enhance change in a resident's behavior [30]. This suggests feedback from patients with rather positive experiences might be less effective in order to enhance residents' learning. Nevertheless, to ensure that residents obtain a variety of both positive and negative feedback from patients, it is recommended to involve a range of patients when seeking patient feedback. This could be achieved by assigning, for example, an assistant to collect feedback from patients instead of the residents or collect feedback regularly on a specific part of the day, for instance, a morning per month.

*Patient Feedback to Enhance Residents' Learning: A Patient and a Resident Perspective DOI: http://dx.doi.org/10.5772/intechopen.108569*
