Research Report

Learning/Feedback Activities and High-Quality

Teaching: Perceptions of Third-Year Medical
Students during an Inpatient Rotation
Dario M. Torre, MD, MPH, Deborah Simpson, PhD, James L. Sebastian, MD, and
D. Michael Elnicki, MD

Abstract
Purpose
To identify specific learning activities (and
teaching methods) that students
associate with high-quality teaching in
the inpatient setting.
Method
For ten months in 2003 04, 170 thirdyear medical students recorded data on
learning/feedback activities and teaching
quality via personal digital assistants
during the inpatient portion of a required
two-month medicine clerkship at four
sites affiliated with the Medical College
of Wisconsin. Univariate and multivariate
analyses were performed to assess the
association between learning/feedback
activities and students perceptions of
high-quality teaching.
Results
A total of 2,671 teaching encounters

Medical education faces important

were rated by 170 students during their

required inpatient medicine rotations.
Bedside teaching was reported in almost
two-thirds of teaching/learning
encounters. Feedback on case
presentation and differential diagnosis
were the inpatient feedback activities
most often provided by faculty. The
univariate analysis revealed that students
perceptions of high-quality teaching was
associated with receiving mini-lectures,
developing short presentations on
relevant inpatient topics, bedside
teaching, case-based conferences,
learning electrocardiogram and chest
X-ray interpretation, teaching with other
team members present (p . 001), and
receiving feedback on history and
physical examination, on case
presentation, at the bedside, on
differential diagnosis, and on daily
progress notes. Results from the

Dr. Elnicki is professor of medicine, University of

Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania.

In the last decade, several medical schoolowned or affiliated hospitals have

undergone mergers, acquisitions, or
closures.1 Medical schools are clearly
feeling the pressure to adapt to changes
in the health care market while struggling
to maintain excellence in medical
education.2,3 A decrease in the number of
inpatients available for students
education, as well as increasing
administrative responsibilities for faculty
amidst increasing demands on their
clinical productivity, have made teaching
of medical students and residents a
challenging task for academic
physicians.4 7 Thus, in such an eroded
and increasingly managed clinical
educational environment, it becomes
important to identify specific learning
activities and teaching methods that
students associate with effective teaching.

Correspondence should be addressed to Dr. Torre,

Medical College of Wisconsin/Clement J Zablocki VA
Medical Center, Froedtert East Office Bldg, Suite
E4200, 9200 Wisconsin Avenue, Milwaukee, WI
53226; telephone: (414) 456-6871; e-mail:
dtorre@mcw.edu.

We recently reported, using students

near-time (time close to the point of care
or clinical encounter) personal digital
assistant (PDA)-based data to the point

challenges in todays academic

environment. Changes in the health care
system have had a significant impact on
the mission of academic medical centers.

Dr. Torre is assistant professor, Department of

Medicine, Medical College of Wisconsin, and the
Clement J. Zablocki Veterans Affairs Medical Center,
Milwaukee, Wisconsin.
Dr. Simpson is professor of family and community
Medicine, Department of Family Medicine and Office
of Educational Services, Medical College of
Wisconsin and the Clement J. Zablocki Veterans
Affairs Medical Center, Milwaukee, Wisconsin.
Dr. Sebastian is professor of medicine,
Department of Medicine, Medical College of
Wisconsin and the Clement J. Zablocki Veterans
Affairs Medical Center, Milwaukee, Wisconsin.

950

regression analysis revealed that giving

mini-lectures on inpatient topics,
teaching electrocardiogram and chest
X-ray interpretation, providing feedback
on case presentation, and at the bedside
were predictors of overall high-quality
teaching.
Conclusions
Aspects of feedback, giving minilectures, and learning test-interpretation
skills were the learning and feedback
activities associated with students
perceptions of high-quality teaching. In
an increasingly time-pressured inpatient
environment, clinical educators should
understand which activities students
value.
Acad Med. 2005; 80:950954.

of care, that receiving high-quality

feedback and proposing a plan were
teaching activities most strongly
associated with students perceptions of
high-quality teaching during a third-year
medicine clerkship.8 However, our
previous report had limitations. First, we
could not identify which feedback
activities, related to third-year clerks
clinical core competencies, were
perceived by learners as being of
especially high quality. Second, we could
not determine which teaching methods
or learning activities specific to the
inpatient setting, if any, were associated
with students perceptions of high-quality
teaching.
Moreover, the variables associated with
effective teaching, including feedback,
whether derived from the literature and
empirically validated9 or based on
learners perceptions,10 13 are often
collected at the conclusion of a clinical
rotation. In a study published in 2000,
Kogan and colleagues14 argued that the

Academic Medicine, Vol. 80, No. 10 / October 2005

Research Report

discrepancy between medical students

perceptions of feedback and teachers
experience may be related to the
summative or end-of-rotation approach
to collecting student data about feedback.
Therefore, we hypothesized that using
near-time, PDA-based data collection
may provide a comprehensive and
alternative method to identify learning
and feedback activities that students
associate with high-quality teaching in an
inpatient clinical setting.
Therefore in the present study, we used a
near-time data-collection methodology
to identify inpatient teaching methods
and learning activities related to thirdyear medical students core clinical
competencies that learners perceive as
contributing most to high-quality
teaching.
Method

Study population
Our study population was 170 third-year
medical students who were rotating on a
required two-month internal medicine
clerkship during July 2003 to April 2004.
All students completed at least one
month of inpatient rotation during the
clerkship and 74 (43%) completed two
months of inpatient service.
Students on their inpatient rotation are
randomly assigned to one of four
different sites: Froedtert Hospital at the
Medical College of Wisconsin, The
Clement J. Zablocki Veterans
Administration Medical Center (VA
medical center), St. Joseph hospital, or St.
Lukes hospital, all in Milwaukee,
Wisconsin. Our study included students
that rotated through any of the four sites,
although Froedtert hospital and the VA
medical center accommodate two thirds
of students each rotation. At Froedtert
and the VA medical center, the teaching
attending on the inpatient service
conducts teaching rounds with the team
approximately four times a week, for 90
minutes, and each team includes one
resident, two interns, and two junior
medical students. They focus on cases
presented by students and interns with
frequent bedside interactions involving
primarily the junior medical students.
These teaching sessions focus on
students case presentation skills, physical
examination skills, data interpretation,
and diagnostic decision making. For all
patients, the teaching attending is the

attending on record. At St. Joseph and St.

Lukes, the structure of the inpatient
service and the learning activities
performed by the junior medical students
are similar to those carried out at the
previous two sites with formal teaching
attending rounds four times week for 60
minutes, with the team composed of a
resident, two interns, and one junior
medical student. These teaching rounds
may occur in the hallway or in a
conference room, often involving bedside
interactions. For many of the patients,
the teaching attending is also the
attending of record. At all sites the
attending on record also reviews the
junior medical students written histories
and physical examinations. Students
teaching attendings are with few
exceptions, generalists (general internists
or geriatricians).
All third-year students at Medical College
of Wisconsin receive a PDA at the
beginning of the academic year and
attend a mandatory one-hour orientation
on how to use their PDA.
Data collection
We asked all students on internal
medicine to complete a PDA-based
learning/feedback form two to three
times per week. The clerkship
coordinator downloaded the content
onto a centralized database once a week.
The form contained specific feedback
activities, a list of clinical tasks completed
by the learner, and overall ratings of
teaching quality. For each teaching
encounter, we asked students to enter
information regarding demographics
(rotation type, site of rotation), attending
staff (hospitalist versus nonhospitalist),
teaching methods used (case-based
conference, bedside teaching, minilectures, assigned talks), and if they
received specific instruction on
interpreting chest X-rays and
electrocardiograms (ECGs). We also
asked students to record information as
to whether they received feedback from
attending staff on written history and
physical examination, differential
diagnosis, oral case presentation, and
daily progress notes. Students then rated
the overall quality of each teaching
encounter (outstanding, very good, good,
marginal, unsatisfactory). The clerkship
directors and faculty members involved
in inpatient student teaching participated

Academic Medicine, Vol. 80, No. 10 / October 2005

in the development of the PDA-based

form.
We selected specific instructional
methods, styles, and strategies included
in the form based on a framework of
instructional methods and recommended
learning sites developed by Clerkship
Directors in Internal Medicine to teach
core clinical competencies to third-year
medical students.15 In addition, we
selected and reviewed a number of
articles on teaching methods commonly
used during inpatient attending rounds
and extracted other instructional
strategies or venues, such ECG and chest
X-ray interpretation to include in the
form.16 21 The feedback activities were
selected based on available literature12,2224
and on third-year medical students
clinical core competencies differential
diagnosis, oral case presentation, history
and physical examinationfor which
feedback is a key educational activity.
All teaching methods and feedback
activities were then approved by a
consensus of the group of clerkship
directors and involved faculty members.
The clerkship director presented and
explained the PDA-based form to the
students during orientation. The students
subsequently downloaded the form onto
their PDAs at the beginning of each
clerkship. While the clerkship director
briefly explained each of the form items
to the students, the clerkship director did
not discuss teaching quality or provide
guidance in how to recognize specific
feedback activities.
The clerkship director told the students
that they were expected to record
between three to four teaching
encounters per week. Students, however,
were specifically told that the number of
forms recorded would not affect their
final clerkship grade. Students were asked
to record those teaching encounters that
involved patients with whom they had a
significant level of interaction and
responsibility, defined as patients with
whom they had performed at least two of
the following: a complete history, a
physical examination, a problem list and
differential diagnosis, or a management
plan. Therefore, the majority of the
teaching encounters recorded were about
patients for whom the students were
primarily and directly responsible.
Students were advised to enter, when
possible, most of their data immediately

951

Research Report

encounters. Feedback on oral case

presentation and differential diagnosis
were the inpatient feedback activities
most often provided by faculty. The
frequency of teaching/learning and
feedback activities is reported in Table 1.

Table 1
Teaching Methods and Feedback Activities That Occurred During 2,671 Inpatient
Teaching Encounters among 170 Third-Year Medical Students, Medical College
of Wisconsin, Milwaukee, 2003 04
Activity

% Frequency

Bedside teaching

62

Mini-lectures

53

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Case-based conference

37

Teaching chest X-ray interpretation

29

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Teaching ECG interpretation

22

Assigning talks

22

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Receiving feedback on differential diagnosis

47

Receiving feedback on oral case presentation

46

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Receiving feedback at the bedside

37

Receiving feedback on written history and physical examination

36

Receiving feedback on a daily progress note

26

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

after the occurrence of the teaching

encounter, or at the end of the day.
Data analyses
We computed descriptive statistics for all
learning and feedback activities.
Univariate (chi-square test) and
multivariate analyses (stepwise multiple
logistic regression) were performed to
assess associations between students
learning activities and teaching methods
and students perceptions of high-quality
teaching.
We performed multivariate logistic
regression analysis with teaching quality
as the dependent variable and
independent variables that included
teaching methods (such as giving minilectures on inpatient topics, case-based
conference, bedside teaching, assigning
talks to students on selected topics,) test
interpretation (teaching ECG and chest
X-ray interpretation), specific feedback
activities (providing feedback on oral case
presentation, at the bedside, on written
history and physical examination, on
daily progress notes, on differential
diagnosis), inpatient teacher category
(hospitalist versus nonhospitalist), and
teaching format (one-on-one versus with
team members present).
We used chi-square tests for significance
to analyze categorical variables. The
outcome variable of interest (teaching
quality) was dichotomized in high quality
(outstanding/very good) and low quality
(good, marginal, unsatisfactory).
Due to the high number of observations,
we established an a priori p value of less

952

than .001 to indicate statistical

significance. Results of the multivariate
analysis are reported as odds ratios with
95% confidence intervals (CIs).25 We
performed all analysis using Intercooled
Stata version 7 (StataCorp LP, College
Station, Texas)

The univariate analysis revealed that

students perceptions of high-teaching
quality were associated with the following
teaching methods and learning activities:
bedside teaching, learning ECG and chest
X-ray interpretation, receiving minilectures on relevant inpatient topics,
case-based conferences, assigning talks on
specific inpatient topics, and teaching
with other team members present (p
.001). Furthermore, all feedback activities
reported by students (feedback on
written history and physical examination,
on differential diagnosis, on oral case
presentation, on a daily progress note,
and feedback at the bedside) were
associated with students perceptions of
high-quality teaching (p .001).
In the univariate analysis, bedside
teaching was associated with teaching
ECG and chest X-ray interpretation;
receiving feedback on oral case
presentation, differential diagnosis,
history and physical examination
(p .001); and with having a
nonhospitalist as teacher (p .05).
Students were more likely to receive
feedback when teaching was done at the
beside compared to other teaching
locations (p .001).

Because the use of PDA-based tools is an

integral part of the clerkship and part of a
formative evaluation process to improve
the quality of students education, the
Medical College of Wisconsins
Institutional Review Board exempted this
project from review.
Results

We collected a total of 3,372 learning/

feedback forms. Incomplete forms
(no. 177) and forms collected in
the ambulatory setting (no. 524)
were excluded from the analysis. We,
therefore, analyzed 2,671 learning/
feedback PDA-based forms. Because
scheduled teaching attending rounds
occurred approximately four times a
week, the total number of teaching
sessions was 2,720 (16 per month
170 students). Therefore 98% (2,720/
2,671 98%) of all teaching encounters
were rated by 170 third-year students
during their required inpatient medicine
rotation.

We found an association between being a

nonhospitalist and teaching chest X-ray
interpretation (p .001). However we
found no other significant associations
between being a hospitalist and teaching
methods or feedback activities.
The regression analysis revealed that
giving mini-lectures on inpatient topics,
teaching ECG and chest X-ray
interpretation, providing feedback on
oral case presentation and at the bedside
remained predictors of overall highquality teaching. Teaching methods and
feedback activities independently related
to high-quality teaching and their
magnitudes of effect are shown in Table 2.

The encounters occurred at four different

inpatient sites, and the teaching attending
was a hospitalist in 43% of encounters.
The teaching attending taught in the
presence of other team members in 83%
of encounters. Bedside teaching was
reported in almost two-thirds of recorded

Discussion

Providing feedback at the bedside,

providing feedback after oral case
presentations, giving mini-lectures on the
wards, and teaching test interpretation

Academic Medicine, Vol. 80, No. 10 / October 2005

Research Report

Table 2
Multiple Logistic Regressions: Teaching Methods and Feedback Activities
Associated with Perception of High-Quality Teaching among 170 Third-Year
Students during 2,671 Inpatient Teaching Encounters, Medical College of
Wisconsin, Milwaukee, 2003 04
Activity

Odds ratio*

95% CI

p Value

Case-based conference

1.4

1.01.4

.009

Bedside teaching

1.0

.741.4

.90

Assigning talks

1.2

.901.6

.24

Teaching chest X-ray interpretation

2.1

1.32.5

.001

Teaching ECG interpretation

2.2

1.42.6

.001

Mini-lectures

2.4

1.83.2

.001

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Receiving feedback on written history and

physical examination

1.1

.901.5

.34

Receiving feedback on oral case presentation

2.0

1.22.8

.001

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Receiving feedback on differential diagnosis

1.6

1.22.3

.002

Receiving feedback at bedside

2.2

1.63.2

.001

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

Receiving feedback on daily progress notes

1.2

.901.7

.3

One-on-one teaching

0.71

.501.0

.06

Being a hospitalist

0.83

.961.0

.09

.........................................................................................................................................................................................................
.........................................................................................................................................................................................................

* Odds ratio 1 the teaching activity was positively related to high-quality teaching. Odds ratio 1 the
teaching activity was negatively related to high-quality teaching.

Statistically significant, 95% CI not including 1, and p .001.

skills (chest X-rays and ECGs) were the

teaching methods and feedback activities
associated with students perceptions of
high-quality teaching during an inpatient
medicine rotation.
These findings are consistent with the
developmental progression of the RIME
(Reporter, Interpreter, Manager/
Educator) paradigm.26 One of the key
developmental goals for third-year
medical students according to the RIME
framework is the progression from
reporter (data gathering) to the
interpreter stage where the student
interprets data to develop an appropriate
differential diagnosis. Our results reveal
that students highly valued opportunities
to learn the interpretation of diagnostic
tests frequently encountered in the
inpatient setting, such chest X-rays and
ECGs. Although clerkship directors
generally agree that students should learn
interpretation of chest X-rays and
ECGs,27,28 our results indicate that such
teaching from faculty occurred in only
one-fourth of teaching encounters. Our
data do not illuminate whether time
constraints on the wards, or facultys
preparedness to include ECG and chest
X-ray teaching in their attending rounds,
were potential barriers to these learning
activities occurring more frequently.
Nonetheless, previous research has
shown that residents and interns are

more likely than are faculty to be the

primary teachers of test interpretation.29
It may be that faculty members who
teach these skills are going beyond the
norm, and hence why teaching these
interpretive skills is viewed as a highquality activity.
While Irby10 and others have reported
that learners have difficulty recognizing
feedback when given, in our study
students recorded that they had received
high-quality feedback in 64% or more of
their teaching encounters. This finding
seems to support the use of PDA devices
as useful tools for near-time recording
and recognition of feedback interactions
that may be missed using the traditional
end-of-course evaluation approach.
Feedback is most effective when it is
timely and focused on specific behaviors
and/or events.15 The use of PDAs allows
feedback to be associated with specific
teaching interactions near the time they
occur and/or may prompt the learner to
recognize feedback due to the cueing
effect of recording the interaction on the
PDA. Moreover, the use of PDAs or other
handheld devices can help clerkship
directors collect information on the
actual occurrence of specific learning
activities, information that can be used as
an indicator of how well a program and
its teaching faculty are fulfilling their
educational mission.15

Academic Medicine, Vol. 80, No. 10 / October 2005

Previous literature has shown a

progressive decline in the practice of
bedside teaching.30,31 Somewhat
unexpectedly, we found a surprisingly
high frequency of bedside teaching
during attending rounds. Whether the
use of near-time recording devices
facilitated increased recall and accuracy
regarding the occurrence of bedside
teaching or whether increased pressure
for clinical productivity has shifted
teaching back to the bedside should be
further explored. Interestingly, our study
indicated that bedside teaching alone was
not an independent predictor of students
perceptions of high-quality teaching. The
critical element was that when students
received feedback at the bedside, an
independent association with highquality teaching emerged. Such difference
may have been related to a disparity in
attendings bedside teaching abilities
(although not in terms of hospitalist
versus nonhospitalist) or that teaching at
the bedside created more opportunities
for feedback. Thus it is possible that
learners perceived bedside teaching to be
an effective learning activity only when it
included active learning methods, (i.e.,
feedback) that engaged them in doing,
discussing, and reflecting. Nevertheless, it
is important to recognize that the
bedside remains an extremely effective
learning setting where a variety of
meaningful educational activities such as
discussion, participation, inquiry, and
feedback occur among members of the
team.
Being a hospitalist was not an
independent predictor of high- or lowquality teaching. Although our primary
intent was not to compare teaching
ratings of hospitalist versus
nonhospitalist, our findings agree with
those of Hunter et al.,32 who
demonstrated that hospitalists are able to
provide at least as positive an educational
experience as nonhospitalist teaching
faculty.
While we did not demonstrate that our
students perceptions of high-quality
teaching translated into effective learning,
there is emerging evidence that clinical
teaching ability has a positive and
significant effect on medical students
learning.3336 Therefore, it is critical that
educators identify and then use those
learning activities that can both maximize
teaching time and students learning.

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Research Report

Our study had several limitations. First,

we conducted the study in a single
institution focusing on third-year
medical students. Second, we evaluated
only learning activities and teaching
methods of a single rotation, so it is
possible that students perceptions
regarding what constitutes high-quality
teaching in the inpatient setting would
have varied by clinical rotation and/or
level of training (e.g., fourth-year medical
students). Third, the decision to focus on
faculty as the primary teacher may limit
the generalizability of these findings to
others who teach medical students (e.g.,
residents, fellows). Students may perceive
that the teaching/learning activities
associated with high-quality teaching by
residents differ from those associated
with faculty.
In conclusion, in an educational
environment increasingly influenced by
health care market changes and by a
decreasing number of inpatients for
medical student education, clinician
educators should select learning and
feedback activities that students perceive
as high quality. PDAs can be a useful tool
to document and ensure that students
have achieved a core set of learning
experiences that are relevant to the
rotation-specific curriculum objectives.
PDAs can capture rich detail about
students curricular activities and their
perceptions of them. Studies aimed at
assessing the teaching process using
learners evaluation should consider the
use of near-time PDAs rather than
postclerkship questionnaires.

6 Blumenthal D, Causino N, Campbell EG,

Weissman JS. The relationship of market
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24 Vaughan L, Baker R. Teaching in the medical

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8 Torre DM, Sebastian JL, Simpson DE.

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25 Garrett JM. Odds ratios and confidence

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9 Litzelman DK, Strtaos GA, Marriott DJ, et al.

Factorial validation of a widely disseminated
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teachers. Acad Med. 1998;73:68895.

26 Pangaro L. A new vocabulary and other

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10 Irby DM. What clinical teachers in medicine

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Academic Medicine, Vol. 80, No. 10 / October 2005