ArticlePloS one2026
Building an implementation framework for directly observed feedback by attending physicians.
Article in PloS one, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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4 authors.
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Abstract
backgroundEffective formative feedback from attending physicians to residents is critical for competency-based medical education. Feedback curricula commonly focus on simulated feedback delivery while actual verbal feedback delivery is unobserved by anyone other than the individuals involved. External observation of feedback has received limited attention as a novel method of improving feedback quality. Despite this, there is no research describing attitudes towards directly observed feedback.
methodsWe developed two surveys, one for Internal Medicine residents (IMRs) and one for hospitalists, who specialize in comprehensive care of hospitalized patients, at the University of Washington in Seattle, Washington in 2023. Survey validity evidence was gathered prior to disseminating surveys via a census sampling approach by group email listservs. Quantitative questions were analyzed by dichotomizing Likert responses as neutral/disagree vs. agree. Free text comments were qualitatively analyzed via a general inductive approach until theme sufficiency was reached. Survey development and analysis was conducted using a lens of social cognitive theory.
resultsThe response rate was 71% (130/184) and 57% (74/129) for IMRs and hospitalists respectively. Most residents and hospitalists reported feeling comfortable with having a feedback exchange observed (105/129, 81%; 46/72, 64% respectively). Hospitalist and IMR concerns about the implementation of directly observed feedback were categorized into three themes: concerns about the relationship with the faculty observer, negative impact on learning environment, and altered feedback quality. Hospitalist and IMR suggestions for parameters to mitigate the challenges of observed feedback were categorized into three themes: the feedback observer's relational boundaries, empower participant agency, and preserve feedback integrity.
conclusionThe thematic concerns expressed by both cohorts relate to social monitoring, either of a projected self-image or to the educational safety of a learner. These themes highlight the fundamental importance of psychological safety in developing a program of directly observed feedback for attending physicians and residents.
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