Chapter 6: Discussion, Conclusion and Recommendations
6.2 Main Findings and Conclusions
6.2.3 What is the relationship between demographic factors and the giving and
The relationship between various demographic factors and how feedback was given and received by consultants and registrars was scrutinised in Chapter 4.
Consultants were on average 37.8 years old (range 31–55). The majority of consultants were Indian (27), female (20), had been consultants for less than five years (20) and spoke English as their first language (31), whilst six were speakers of other languages. The mean age of the registrars was 32.3 years (range 27–43). The majority of the registrars were Indian (20) and female (24). Most of the registrars (16) were in their fourth year of Registrar training, 12 were in their third year, seven were in their second year, and two had just commenced training. The effect of age, race, gender, language, year of study and
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discipline were examined to see how these factors impacted on the provision and receipt of feedback.
Age did not significantly influence the overall perceptions of the quality of feedback given or received for either consultants or registrars, although the older consultants were perceived to be more experienced and therefore better at providing feedback. No statistically significant relationship was noted between individual variables and race for registrars. Indian consultants, unlike their African or white colleagues, gave significantly more specific feedback about how to be a communicator (a graduate competency outcome) and felt that were proficient at giving feedback to registrars. Male consultants reported being more competent at providing feedback than female consultants, and male registrars reported more favourable outcomes following feedback than did females.
Consultants who were first language English speakers gave more feedback about how to be a communicator and a collaborator than consultants who spoke English as a second language. Registrars who were second language English speakers reported statistically significantly more favourably on most of the aspects of the feedback that they received.
Surgical consultants reported that they gave better feedback as compared to consultants in the other disciplines, and their registrars concurred, except that they noted they would not use these techniques with their own students. Registrars in the second year of training upwards felt that they did not receive feedback as often or sufficiently, as compared to first year registrars, who reported receiving feedback based on direct observation of performance, that it incorporated a plan for improvement, and that they received adequate support after a session.
The study found that the consultants who were not African were affected more than African consultants by the race of the registrar they were giving feedback to. This is of concern since feedback should be given in a non-partisan manner, and registrars should feel safe within ‘decolonialised’ and non-racial teaching spaces (Badat 2015). Male consultants and registrars generally had a more favourable opinion of the success of feedback given and received than females. Gender discrimination has been cited as a reason for greater attrition of female students from medical school, as well as unfair representation in positions of power (Harp et al. 2016, Newman et al. 2016), indicating
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that female registrars and consultants should be empowered to seek out, as well as provide, feedback more effectively. Although consultants who were English first language speakers (EFL) were at pains to improve the communication skills of registrars who were English second language speakers (ESL) with regards to interviewing patients, possibly due to acknowledging difficulties in communication in a language that was not the registrar’s mother tongue, care must be taken to improve all round communication, especially explicit directives that feedback is being provided – and this, to all registrars.
The message ‘transmitted’ must be ‘received and understood’ (Murdoch-Eaton 2012).
Good communication between registrar and consultant also impacts on the ability of both participants to reflect on the process (Ramani and Krackov 2012), which has the long- term benefit of development of personal maturation and cognition (Sandars and Jackson 2015). Senior registrars require just as much, if not more, feedback, as junior registrars.
Angus et al. (2015) found that registrars benefitted from milestone-based feedback. This was a form of feedback based on specific development and progression of skills. Hence, as the registrar progressed through training and acquired more skills, feedback on performance had a greater effect than more general feedback when competencies had not yet had a chance to be as developed. Feedback must be provided equally across all the years of training, so as not to disadvantage senior registrars, more especially as they are nearing the end of their training and coming closer to independent practise. Although favourable outcomes were reported for the discipline of Surgery in both giving and receiving feedback, there appeared nonetheless flaws inherent in the process, as evidenced by registrars not wanting to use these methods with their own students.
The study found that the relationships that were observed between various demographic factors and provision of feedback, can negatively impact on registrars acquiring the competencies necessary to be well-trained physicians. Therefore, in order to make a more detailed analysis of the interrelationship between these factors identified, as well as the context or environment in which feedback is given, the content and process of feedback, as well the ‘actors’ – the multiple stakeholders involved with giving and receiving feedback, interviews were conducted with key informants to identify not only impediments to the process, but to underscore strengths and opportunities for improvement.
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6.2.4 How do the actors (key role players), and the contextual, content and process