Understanding of Sociocognitive Theory Can Improve Medical Student Training
Key findings
- This study applied the theory of planned behavior (TPB) and the theory of interpersonal behavior (TIB) to understand how medical students plan to apply the feedback they received during their obstetrics and gynecology clerkship
- 122 students recorded 1,912 pieces of feedback they received from attending physicians, fellows and residents, including 1,443 statements about what they planned to change based on the feedback
- 85% of students' statements about intention to change were related to self-efficacy (a belief they could learn to perform a task); only 11% were related to attitudes and beliefs (the outcome of performing the task), and 9% to meeting expectations
- Yet overall trainee performance may be improved by associating feedback about a desired behavior change with a patient's care experience, clinical outcomes, and the need for efficient clinical teams
- When teaching students how to solicit and use feedback—and when teaching faculty how to provide meaningful feedback—it is important to invoke the TPB domains of attitudes and beliefs, and subjective social norms
Faculty feedback based on direct observation is required for trainees to develop and improve their skills, but in several studies, undergraduate medical students have consistently reported receiving inadequate feedback.
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In 2018, leaders of the obstetrics and gynecology clerkship at Harvard Medical School developed the Feedback Focused initiative, designed to improve the quantity and quality of feedback provided to medical students. Ilona Telefus Goldfarb, MD, MPH, maternal–fetal medicine specialist in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, Natasha R. Johnson, MD, director of undergraduate medical education in the Department of Obstetrics and Gynecology at Brigham and Women's Hospital, and colleagues report in Medical Science Educator about the insights they gained.
Methods
The initiative was based on two sociocognitive theories commonly used to understand trainee and clinician behavior:
- The theory of planned behavior (TPB) holds that three components influence behavioral intentions: attitudes and beliefs (the learner is motivated by the outcome of performing the behavior), subjective social norms (the learner is motivated to meet the expectations of a person or group) and self-efficacy (the learner believes they can perform the task or overcome obstacles to performing the task)
- The theory of interpersonal behavior (TIB) extends the TPB by adding an emotional/affective component: behavioral intentions are not based simply on conscious behavior but also on emotions evoked while performing some behavior
Between July 2, 2018, and May 30, 2019, the Feedback Focused curricular innovation was implemented in the OB/GYN clerkships at all four Harvard Medical School–affiliated teaching hospitals. All attendings, fellows, and residents in OB/GYN settings were included.
144 students were asked to record verbal feedback in a pocket notebook at least once per day. They also tracked the nature of that feedback (source, setting, type, and whether the feedback was constructive) and answered, "What do you plan to change?" Two researchers coded each response as aligning within any of the four TPB and/or TIB components.
Results
122 students returned their notebooks. 1,912 pieces of feedback were recorded, evenly distributed among inpatient and outpatient settings and the operating room. 1,443 entries (76%) included substantive text about intended changes. The TPB/TIB components represented were:
- Self-efficacy—85% of responses; learners used words such as "be sure to," "try to," and "work on," emphasizing their role in making changes
- Attitudes and beliefs—11%, commonly expressed as an intention to change the outcome for a patient
- Subjective social norms component—9%; most students reported intentions to change to meet the standards or expectations of a setting, team, or individual clinician
- Emotional responses—1.7%
Negative emotional responses often related to one case or a single faculty member who gave confusing feedback, had idiosyncratic preferences, or seemed uninterested in teaching.
Positive emotional responses included learners reporting value in hearing that they should not be afraid to speak up or that they are appreciated and trusted to provide patient care. Some students gained newfound awareness that it is acceptable to stop, think and regain poise before proceeding in challenging care situations.
The percentages add to more than 100 because some responses were coded as representing more than one TPB/TIB component.
From Individual Learner to Clinical Team Member
The self-efficacy domain is familiar to students and faculty, as it relates to encouraging improving technical and interaction skills. However, when teaching learners how to solicit and utilize feedback—and when teaching faculty how to provide meaningful feedback—it is just as important to invoke the domains of attitudes and beliefs and subjective social norms.
Verbally relating a desired behavior change to a patient's care experience and clinical outcomes may improve trainee performance. Professional identity formation is in its infancy during medical school, and feedback in those two domains helps trainees understand their role as contributors to efficient clinical teams, not just as medical students on a clerkship.
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