Literature on medical education consists of only a few studies that specifically evaluate the teaching of psychiatry to undergraduate medical students. To date, the role of formative feedback in this area has been neglected by medical educators. Formative feedback has been defined as "information about how successfully something has been or is being done" (+1, p 120) and is provided to help individuals improve their performance. Formative feedback is not used for summative purposes, but for facilitating the identification of strengths and weaknesses and ways in which to further develop one’s skills.

In 1995 Rolfe and McPherson (+2) lamented that the education literature had focused heavily on summative assessment at the expense of formative methods. While there is now recognition of the importance of formative feedback and assessment in medical education, researchers have not yet redressed the balance. Most considerations of formative methods have addressed postgraduate students (+3, +4), none of whom were training in psychiatry. An important exception is the Leicester Assessment Package (+5), a formative tool for undergraduate use. However, this package has not been used specifically in relation to psychiatry teaching.

This study describes the introduction of formative feedback to an undergraduate psychiatry curriculum at one teaching site at an Australian University and discusses efforts to include formative feedback in psychiatry teaching, and considers students’ perceptions of and responses to formative feedback.

In 2001 there were 128 students enrolled in Medicine IV at the University of Adelaide. For their psychiatry attachment 63 of these students were randomly placed at "Hospital 1," 65 at another, "Hospital 2." We implemented a formal formative feedback session at Hospital 1, but the teaching staff at Hospital 2 chose not to do so. Thus, this study pertains only to the 63 students at Hospital 1.

A consultant psychiatrist (the second author), who taught and observed the students throughout their attachment, saw each student individually at Week 4 of the 6-week attachment at Hospital 1. Students were initially asked how they felt the attachment was proceeding and if they had any specific concerns. Feedback was then given according to a "clinical attachment assessment form," where students were rated as "satisfactory," "borderline" or "unsatisfactory." In accordance with the university guidelines, three broad categories were assessed on the Form: attitude and professional behavior (reliability, attendance, patient and staff interaction), clinical skills (history taking, mental state examination, verbal presentation, tutorial contribution, interviewing skills, written communication), and clinical knowledge (ability to match clinical findings to theoretical concepts and management plans). At the formative feedback sessions, areas of concern and strength were highlighted, and students were given an opportunity to discuss any issues they thought relevant to their progress and the attachment. They were told that the same Form would be used for their summative assessment at the end of the attachment. It was, however, stressed to them that the purpose of this session was to give them feedback as to their progress, and help identify areas for improvement, and not as an assessment per se of their performance. Sessions ranged in duration from 10 to 30 minutes.

At the end of each 6-week period, prior to the final summative examinations, each student was asked to complete an anonymous questionnaire. They were asked to rate various aspects of their teaching experience during the psychiatry attachment for the purpose of staff professional development. They were also asked to define "formative feedback," indicate whether they had received such feedback during the attachment (yes or no), and if yes, indicate how useful it had been, on a scale from 7 (very) to 1 (not at all). Descriptive statistics were conducted using SPSS-X, while qualitative data were subjected to content analysis by the two authors who conferred after analyses to reach agreement.

Evaluation questionnaires were completed by 62 (98.4%) of the students. Of the definitions of formative feedback provided by students, the authors agreed that 5 were incorrect. These five students’ responses were excluded, since we could not be confident that their ratings and comments were valid; thus the results pertain to the remaining 57 (91.9%) questionnaires.

All but one student at Hospital 1 said that they had been given feedback. For those who had been given feedback, the majority (87.5%) rated it above the midpoint of 4 in terms of how helpful it had been, with a rating of 6 being the most frequent (43.8%). The mean rating was 5.5.

Forty-six students (80.7%) chose to make a written comment about the usefulness of formative feedback. These data were categorized, and are presented in +Table 1. Students were generally positive about the process and benefits of formative feedback, although a number of students felt that feedback should always include constructive criticism and should be more formal and structured. One student stated, "Negative comments are most welcome;" others wrote, "I would have appreciated more detailed identification of areas to improve," and "Feedback was pretty vague—clarity in strengths and weaknesses was not pointed out." Students said that feedback identified areas for improvement, was reassuring or increased confidence and was useful. One student commented, "I already had a fair idea of where I was at—it was just reassuring;" another said, "It gave me more confidence, to think optimistically."

This study describes an attempt to formally introduce formative feedback into an undergraduate psychiatry attachment, and to gauge students’ responses to that initiative.

It is obvious that setting aside specific teaching time for the purpose will result in students being provided with formative feedback, and most educators are well aware that students are keen to receive feedback. That all but one of our students had been provided with formative feedback supports the first notion, and the fact that the majority rated it highly concurs with the second.

Students’ open-ended comments are interesting but should be viewed in the context of preliminary data that might be informative as the basis of a survey questionnaire for future students. Comments about the usefulness of formative feedback suggest that regardless of whether it was provided or not, students want it and think that it is important, both from a practical point and also psychologically, by increasing confidence and helping the students feel reassured that they are on the right track. However, students also indicated that they want rigorous, meaningful feedback, allowing for structure, formality, and constructive criticism, not glib reassurances that give them no direction. Pro formas are sometimes used to provide formative feedback (+6), or feedback is written following verbal exchange (+5). On the basis of these students’ comments, these measures are recommended in order to facilitate the provision of constructive criticism and provide structure.

While formative feedback was offered at Hospital 1, the same initiative was not introduced at Hospital 2. Some clinical teachers may consider formative feedback to be unnecessary or time-consuming, and hence specific times are not set aside for the activity. The responses from the students at Hospital 1 indicate that such feedback is needed and appreciated, and that even as little as ten minutes may be sufficient. Thus, we would encourage formative feedback to be integrated into psychiatry training curricula. A comparison of the summative results of the two hospitals would have been informative, but since so many other variables differed in addition to the provision of formative feedback for which we could not control, including the clinical teachers and the cases seen, this was not possible. Ethically, we felt we could not withhold formative feedback from one-half of the students at Hospital 1 for research purposes, which would have been one way of evaluating positive benefits of feedback.

This study indicates that formative feedback that focuses on clear and specific suggestions for improvement is seen as more valuable than simply telling students "about how successfully something has been or is being done" (+1). We are not able to determine whether formative feedback impacted in any way upon summative assessments, and this is an area of inquiry that needs to be pursued empirically. Indeed, rigorous research is required to consider how formative feedback should be delivered, as well as how it might impact student learning in the short and longer terms. We hope this descriptive study will encourage colleagues to consider both introducing formative feedback into curricula and to evaluate its educational impact.

The authors thank Ms. Kaye Brown and Ms. Lara Duff who distributed and collected the questionnaires at the two teaching sites and the students for their cooperation.