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Reflections From the Rearview Mirror: Internal Medicine Physicians’ Reactions to Clinical Feedback After Transitions of Responsibility

Bowen, Judith L. MD; Ilgen, Jonathan S. MD, MCR; Regehr, Glenn PhD; Cate, Olle ten PhD; Irby, David M. PhD; O’Brien, Bridget C. PhD

doi: 10.1097/ACM.0000000000002831
Research Reports

Purpose Learning from practice is important for continuous improvement of practice. Yet little is known about how physicians assimilate clinical feedback and use it to refine their diagnostic approaches. This study described physicians’ reactions to learning that their provisional diagnosis was either consistent or inconsistent with the subsequent diagnosis, identified emotional responses to those findings, and explored potential consequences for future practices.

Method In 2016–2017, 22 internal medicine hospitalist and resident physicians at Oregon Health & Science University completed semistructured interviews. Critical incident prompts elicited cases of patient care transitions before the diagnosis was known. Interview questions explored participants’ subsequent follow-up. Matrix analysis of case elements, emotional reactions, and perceived practice changes was used to compare patterns of responses between cases of confirming versus disconfirming clinical feedback.

Results Participants described 51 cases. When clinical feedback confirmed provisional diagnoses (17 cases), participants recalled positive emotions, judged their performance as sufficient, and generally reinforced current approaches. When clinical feedback was disconfirming (34 cases), participants’ emotional reactions were mostly negative, frequently tempered with rationalizations, and often associated with perceptions of having made a mistake. Perceived changes in practice mostly involved nonspecific strategies such as “trusting my intuition” and “broadening the differential,” although some described case-specific strategies that could be applied in similar contexts in the future.

Conclusions Internists’ experiences with posttransition clinical feedback are emotionally charged. Internists’ reflections on clinical feedback experiences suggest they are primed to adapt practices for the future, although the usefulness of those adaptations for improving practice is less clear.

J.L. Bowen was professor, Department of Medicine, Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health & Science University, Portland, Oregon, at the time of the study. The author is now professor, Department of Medical Education and Clinical Sciences, and associate dean for curriculum, Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington; ORCID:

J.S. Ilgen is associate professor, Department of Emergency Medicine, and associate director, Center for Leadership and Innovation in Medical Education, University of Washington School of Medicine, Seattle, Washington.

G. Regehr is professor, Department of Surgery, and senior scientist and associate director of research, Centre for Health Education Scholarship, University of British Columbia, Vancouver, Canada, and holds an affiliated appointment with the Maastricht University School of Health Professions Education, Maastricht, the Netherlands.

O. ten Cate is professor of medical education, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands, and adjunct professor of medicine, School of Medicine, University of California, San Francisco, San Francisco, California.

D.M. Irby is professor emeritus of medicine, School of Medicine, and senior scholar, Center for Faculty Educators, University of California, San Francisco, San Francisco, California.

B.C. O’Brien is associate professor of medicine, School of Medicine, and education scientist, Center for Faculty Educators, University of California, San Francisco, San Francisco, California.

Supplemental digital content for this article is available at

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Ethical approval was granted by the Oregon Health & Science University Institutional Review Board, effective December 18, 2015; reference number STUDY00015374.

Correspondence should be addressed to Judith L. Bowen, Elson S. Floyd College of Medicine, Spokane Academic Center, 412 East Spokane Falls Blvd., Spokane, WA 99202; email:

Copyright © 2019 by the Association of American Medical Colleges