Evaluative (Mis)alignment in Competency-Based Feedback: A Constructivist Grounded Theory-Informed Study in Family and Community Medicine Residency Programs
This constructivist grounded theory study of family medicine residency programs in Brazil reveals that evaluative misalignment between residents and preceptors stems from divergent reasoning rather than scoring discrepancies, leading to the development of the S-SKILLS-F framework to transform feedback into a negotiated, actionable process for professional growth.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the world of medical training, there is a growing belief that the best way to prepare a doctor is not just by memorizing facts, but by mastering a specific set of skills and behaviors known as professional competence. This concept goes beyond knowing how to treat an illness; it involves the ability to think, act, and communicate effectively in the complex, real-world environment of a clinic or hospital. To ensure doctors are ready, training programs use a system called competency-based education, where learners are assessed on their ability to perform specific tasks. A critical part of this system is feedback, a conversation where a teacher, or preceptor, and a student, or resident, discuss how well the student is doing. The hope is that by comparing their views, they can agree on what needs to be learned next. However, a fundamental challenge exists: the teacher and the student often see the same performance through completely different lenses. One might focus on what was actually done, while the other might focus on what the student is expected to do in the future, or what they seem to know in theory. If these two people cannot agree on what "good performance" even means, the feedback conversation can become a missed opportunity for learning.
Researchers in Brazil set out to understand exactly how these conversations unfold in family and community medicine residency programs. They wanted to move beyond asking people how they felt about feedback and instead listen to what they actually said when they sat down to discuss their work. The team gathered fourteen pairs of residents and their preceptors. Before meeting, each person in the pair independently rated the other on thirty-four different professional skills, such as managing patient cases, communicating effectively, and performing medical procedures. They used a simple five-point scale to indicate their level of confidence and mastery. Once the ratings were done, the pairs met in a recorded session to compare their scores. If they agreed, they explained why. If they disagreed, they had to discuss the reasons for the difference and figure out a plan to improve. The researchers then analyzed hundreds of hours of these conversations to see how the judgments were made and negotiated.
The study revealed a surprising truth: the numbers on the rating sheet often told a misleading story. In more than half of the comparisons, the resident and the preceptor gave different scores. But even when they gave the same score, they were often thinking about completely different things. The residents tended to base their self-assessments on what they had actually done. If they had never performed a specific procedure, like inserting an intrauterine device, they gave themselves a low score because they lacked the experience. They judged themselves on their current reality. The preceptors, however, often looked beyond what they had directly observed. They assigned higher scores based on the resident's theoretical knowledge, their general impression of the person, or their belief that the resident would be capable of doing the task if given the chance. A preceptor might say, "I haven't seen you do this, but I know you understand the theory, so I believe you can do it." In these moments, the resident was rating their past actions, while the preceptor was rating their future potential.
This difference in perspective created a gap that the researchers called evaluative misalignment. It was not simply that one person was right and the other wrong; it was that they were evaluating different objects. One was measuring a finished product, while the other was measuring a blueprint. The study found that this misalignment was often hidden by the rating scale itself. Sometimes, a low score was given not because of poor performance, but because the resident felt it was a punishment or a sign of failure. Other times, a high score was given not because the skill was mastered, but to encourage the student or to avoid hurting their feelings. The scale became a tool for managing relationships rather than a precise measure of skill. When the conversations were recorded, the researchers saw that the way the feedback was delivered mattered immensely. If the preceptor spoke first and gave their judgment immediately, the resident often fell silent or simply agreed, shutting down the chance to discuss the real reasons behind the score. But when the resident was allowed to explain their own view first, the conversation became more productive. They could compare their evidence, clarify what they meant by a specific skill, and identify real barriers, such as a lack of equipment or opportunities to practice, that were preventing them from showing what they knew.
From these observations, the researchers developed a new way to structure these feedback sessions, which they named the S-SKILLS-F model. This approach is designed to make the hidden parts of the conversation visible. It starts by ensuring both parties understand the criteria before they begin. Then, the resident shares their self-assessment and the experiences that led to it before the preceptor offers their view. This order allows the resident's perspective to stand on its own. The core of the meeting is not to force a single number, but to discuss the evidence. They ask questions like, "What did you see?" "What did you do?" and "What stopped you from doing more?" They look for the difference between what the resident can do now and what they might be able to do later. Finally, they create a concrete plan for the future, identifying specific actions the resident will take and the support the preceptor will provide. This model treats the feedback session not as a grading event, but as a collaborative investigation into learning.
The study concludes that the problem of differing opinions in medical training is not a flaw in the students or the teachers, but a natural feature of how competence is judged. It is a negotiation between different ways of seeing the world. The research suggests that simply having a list of skills to check off is not enough. To truly help doctors grow, the people involved must take the time to align their definitions of success, to share the evidence they are using, and to understand the context in which the learning happens. The new model offers a path forward, turning a potentially confusing disagreement into a clear, actionable plan for development. While the researchers note that this new approach needs to be tested in other settings to see how well it works in practice, the study provides a clear map of where the current system gets stuck and how to move past it. The findings remind us that in the complex art of teaching medicine, the most important step is often not the assessment itself, but the conversation that happens before, during, and after the score is given.
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