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It was with great pleasure that we read the observational study by Bosner et al  which centres on an aspect salient to all medical students: clinical teacher feedback . A factor highlighted by Lempp et al, found that students were most pleased with teachers who were approachable and provided them with constructive criticism .
As undergraduate medical students at the largest centre for healthcare education in Europe , we benefit from experiences in varied teaching settings; ranging from one-to-one sessions to class sizes of up to 450 students. Our clinical curriculum places strong emphasis in the primary health care setting - where we have accumulated nearly 300 hours between us in around 40 practices, both in and around London.
Whilst Bosner et al  have presented a well-organised and structured study; we challenge some of the intricacies affecting its overall validity and subsequent conclusions, and therefore propose suggestions for improvements. There is an absence of information pertaining to whether the observers (fifth year medical students) were appropriately trained to effectively judge the quality of feedback given by their seniors (clinical teachers). This is then coupled with no mention of any guidelines or reference used as a “benchmark” for this assessment. Both present issues regarding quality assurance - the necessity and impact of which has been highlighted by Lievens .
The presence of the ob...
The presence of the observers may have biased general practitioner (GP) attitudes towards their respective students, an aspect which is further complicated by the fact that in some instances, none of the students collecting the data were present, but instead a video camera . Furthermore, Bosner et al  have not stated what pre-study information was available to the GPs involved as this could similarly influence GP behaviour. In addition, as the project was conducted in only 12 practices and associated with only one university (in Marburg, Germany) there must be a degree of caution with extrapolating the findings to teaching across all GP settings.
Whilst some of the improvements can be interpreted from our suggested limitations, such as evidence of appropriate training and mechanisms in place for quality assurance; we have made additional recommendations after reflecting on our own clinical experiences.
At several points the authors have touched on factors that could help form a vital role in helping understand the reasons behind GP’s verification and feedback, however these have not been developed. For example, Bosner et al  differentiates practices as “urban” or “rural,” but have not stated their findings for particular GPs. Walter et al  found that students in the rural setting performed better in their exams, and hence this distinction may have been informative. Table 2 lists patients’ reason for attending the clinic, ranging from “health education,” to “acute threatening.” This could similarly influence the time the GPs had for student interaction. It therefore may have been of use to stratify the points from Table 1 and 2 with findings of their respective observation sessions, to allow for any correlations to be drawn. Similar organisation of observation findings between field observed and video camera recording sessions may highlight any potential bias in the GPs behaviour as referred to above.
Finally a further subdivision of the feedback given should have been to categorise whether a constructive element was present. Joyner et al  noted constructive feedback as an important feature of medical student learning and development.
In conclusion, we were pleased to read this review and the recommendations for more specific feedback in general practice placements. We agree that such feedback will help undergraduate medical students progress as better clinical practitioners. However, some of the limitations discussed above do impact the use of this study in shaping medical education. Furthermore, identifying the barriers would assist medical educationalists in forming solutions to solve these issues.
1. Bösner, S., Roth, L.M., Duncan, G.F. and Donner-Banzhoff, N., 2017. Verification and feedback for medical students: an observational study during general practice rotations. Postgraduate medical journal, 93(1095), pp.3-7.
2. Ende, J., 1983. Feedback in clinical medical education. Jama, 250(6), pp.777-781.
3. Poulos, A. and Mahony, M.J., 2008. Effectiveness of feedback: The students’ perspective. Assessment & Evaluation in Higher Education, 33(2), pp.143-154.
4. Lempp, H. and Seale, C., 2004. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. Bmj, 329(7469), pp.770-773.
5. Website Accessed on 2/2/2017: http://www.kingshealthpartners.org/about-us/our-partnership
6. Lievens, F., 2001. Assessor training strategies and their effects on accuracy, interrater reliability, and discriminant validity. Journal of Applied Psychology, 86(2), p.255.
7. Baker, P.G., Dalton, L. and Walker, J., 2003. Rural general practitioner preceptors–how can effective undergraduate teaching be supported or improved. Rural and Remote Health, 3, p.107.
8. Walters, L., Worley, P., Prideaux, D. and Lange, K., 2008. Do consultations in rural general practice take more time when practitioners are precepting medical students?. Medical education, 42(1), pp.69-73.
9. Joyner, B. and Young, L., 2006. Teaching medical students using role play: twelve tips for successful role plays. Medical teacher, 28(3), pp.225-229.