Twice as Nice: A Two-Step Process Empowering Medical Students to Co-create narrative feedback

Medical education relies on narrative feedback to improve and assess medical student performance in clinical settings, but ensuring sufficient quality narrative feedback remains challenging. This study examined the impact on quantity and quality of narrative feedback of a "two-step process" in which students first documented verbal feedback received from faculty, and then those same faculty reviewed and modified the feedback recorded by the student.

The two-step process was implemented at Baylor College of Medicine (BCM) in the context of planned direct observations of clerkship students and at Harvard Medical School (HMS) in the context of supervised clinical care by advanced elective students. Narrative feedback after the initiation of the two-step process (2023-2024) was compared to the baseline period (2022-2023). Differences in quantity of narrative feedback were measured by comparing word count and proportion of completed feedback forms (for supervised clinical care at HMS only). Quality of narrative feedback was measured by coding for and comparing markers of quality: behavior-based feedback, specific clinical examples, and absence of trait-based language.

Using the two-step process was associated with increased narrative feedback at both institutions. Median word count per instance of feedback increased from 23 to 50 (P < .001) at BCM and from 75 to 119 (P < .01) at HMS. At HMS, the proportion of completed feedback forms also increased from 42 to 93% (P < .001). The proportion of narrative feedback instances with behavior-based feedback and specific examples significantly increased at both institutions, and use of trait-based language significantly decreased at HMS (P < .05 for all).

A two-step process in which students and faculty co-create narrative feedback is feasible and enhances quantity and quality of feedback in various clinical settings. Future research should explore how student participation in generating narrative feedback impacts participating students and faculty.