Feedback from preceptors is a primary mechanism by which medical students learn and improve their knowledge and clinical skills, particularly as they begin clinical rotations and engage in patient care for the first time. The shift to clinical education, typically in the third year of medical school, is a period of time in which students are applying their medical knowledge, gaining new insights, and developing communication skills. Clinical education is also a setting in which students are observing and “trying on” ways of practicing medicine that reflect and shape their identity as a future physician. Cohen et al. (2009) note how clinical education in particular shapes identity development and transformation in medical students through constant feelings of being an outsider with each rotation; feeling caught between being a student and treated “as-if” they are a physician; and practicing medicine but not yet being credentialled. Hence, feedback from preceptors during clinical education not only provides information about what and how students can improve their performance, but also sends evaluative messages that influence how students think about themselves and their profession (e.g., Am I good enough to be here? Is this specialty right for me?).
From a learning perspective, research supports how feedback enhances medical students’ knowledge, skill development, and motivation—factors that each contribute to improved performance (Burgess et al., 2020). Effective feedback is also tied to important outcomes, including improved communication skills and increased learning (Boehler et al., 2006; Engerer et al., 2019). For example, Bose and Gijselaers (2013) found that medical students who engaged in feedback-seeking behaviors reported increases in professional self-improvement when compared with those who did not. Hughes et al. (2017) constructed a computer-based feedback system that allowed medical students to initiate requests for feedback about their performance. Their findings suggested that medical students who used the system reported more timely, frequent, and useful feedback, increasing the overall quality of their rotation. Finally, McGinness et al. (2020) studied the effects of a student-directed feedback intervention for medical students, finding that even a brief (30–60 minute), one-off workshop improved students’ satisfaction with feedback and their willingness to seek and utilize feedback.
Most studies of feedback during medical training focus on the role of feedback in the learning process (van de Ridder et al., 2015), barriers to delivering feedback (Reddy et al., 2015), and strategies for delivering feedback (Boehler et al., 2006). In addition, the kinds of tasks being assessed are varied; examples of such tasks include systems for providing feedback (Hughes et al., 2017), clinical examination skills (Bösner et al., 2017), and patient-centeredness (Bombeke et al., 2011). Many studies compare the type of feedback students receive with the types of feedback they want, finding that students typically desire constructive, privately delivered feedback while preceptors frequently deliver chiefly complimentary feedback (Kim et al., 2014; Rogers et al., 2012; Rozental et al., 2021; Urquhart et al., 2014). In the current study, we explore students’ attitudes toward feedback from preceptors during clinical rotations and how those attitudes are associated with identify factors, namely, how students view themselves personally (i.e., impostor syndrome) and how they view themselves in relation to the group (i.e., identification with the profession).
Students’ attitudes toward and receptiveness to feedback is referred to as “feedback orientation.” Informed by feedback intervention theory, feedback orientation is “the individual response bias that students possess toward feedback in instructional settings” (King et al., 2009, p. 236). Students’ feedback orientation includes their perceptions of four dimensions of feedback: utility, sensitivity, confidentiality, and retention (King et al., 2009). Feedback utility refers students’ perceptions that teacher feedback is valuable and useful for improving academic performance. Feedback sensitivity is the degree to which students are intimidated or threatened by corrective feedback. Feedback confidentiality refers to students’ concerns about the public/private context in which teacher feedback is provided. Feedback retention is defined as the degree to which students do or do not retain the feedback they receive from teachers. Ideally, medical students’ orientation to feedback improves over time, and they become more comfortable and willing to receive feedback. However, some students may remain sensitive to feedback and have negative attitudes toward it. Few studies examine students’ feedback experiences across the third year of clinical education. This study’s longitudinal approach makes it possible to track changes in students’ orientation to feedback, identifying time points that may need intervention.
RQ1: Does orientation to instructor feedback change during the third year?
How students orient themselves toward feedback and whether feedback is effective is likely influenced by identity-related factors, as feedback can be a face-threatening act. Medical students may be concerned about how others perceive their competence and skill. We propose that both personal identity (i.e., impostor syndrome) and group identity factors (i.e., identification with the group) are related to feedback orientation over time. Commonly, medical students’ own identity is influenced by the impostor phenomenon, also known as impostor syndrome, fraud syndrome, perceived fraudulence, or impostor experience (Bravata et al., 2020). This phenomenon refers to “an internal experience of intellectual phoniness” (Clance and Imes, 1978, p. 241). Many studies examine the impostor phenomenon in medicine (e.g., Baumann et al., 2020; Bravata et al., 2020). Villwock et al. (2016) found that imposter syndrome (IS) was prevalent among a sample of medical students, with nearly half of female students and almost a quarter of male students reporting IS. For medical students, IS manifests in several ways, such as not asking for help for fear of demonstrating weakness and burnout (Dweck, 2008; Villwock et al., 2016). These behaviors have consequences, including more focus on performance as opposed to learning, depression, anxiety, and increased work-related stress (Gottlieb, 2021; Mullangi and Jagsi, 2019). Medical students who experience IS may be resistant to feedback, in part because fear of failure and underperformance is so pervasive (Khan, 2021; LaDonna et al., 2018). In addition, IS intersects with concerns of under-representation, exclusion, and bias—challenges that may speak to why female medical students in particular report high rates of IS (Villwock et al., 2016).
Therefore:
H1: Impostor syndrome is negatively associated with orientation to instructor feedback.
Medical students’ also have an identity tied to peers and physician, or a “sense of belonging to the group, coupled with a sense of commonality with its members” (Sani et al., 2015, p. 1396). Group identity is important to medical students’ feedback needs, as strong group cohesion is beneficial to individuals (i.e., sense of belonging, health outcomes). For instance, group identification, in conjunction with social support, creates more positive reactions to stress (McKimmie et al., 2020). Group identification also facilitates goal attainment through perceptions of group-derived efficacy. Caricati et al. (2020) found that group identification was positively associated with EMS volunteers’ self-efficacy or their ability to provide care in emergency situations. Similarly, in a study exploring the relationship of medical student identity and well-being, McNeill et al. (2014) found that group membership has a positive effect on medical student well-being, suggesting that opportunities to promote shared experience can support their overall wellness. Finally, findings from medical student and resident interventions that address topics such as mindfulness or meditation (Goldhagen et al., 2015), and programs intended to enhance student well-being through social support, engagement, and meaningful connection to others, suggest that these opportunities enhance group identification and serve as a way to promote well-being and reduce burnout (Ziegelstein, 2018). Indeed, medical students who have a stronger group identity are likely more open to feedback because they feel more secure among their peers. Hence:
H2: Group identity is positively associated with orientation to instructor feedback.