Narrative Feedback and Its Multiple Roles

Published on Thursday, December 12, 2024

By: Dr. Lyssa Weatherly

Narrative feedback in medical education is classically considered to be the written comments that assess a student’s performance. However, this is only a snapshot of the bigger picture. Narrative feedback serves not just to highlight learners’ strengths and areas of improvement, but when done well, it also provides a valuable detailed picture of their clinical skills and abilities beyond grades and test scores, which is vital for guiding residency applications via the Medical Student Performance Evaluation (MSPE or Dean’s Letter).  Narrative feedback is not just for the benefit of the student, but for the guidance of program directors when selecting candidates for residency. A national survey of program directors across the country reported that across subspecialties, the majority of respondents valued the narrative comments from the clerkship more than the grade itself.  This emphasizes the importance of reflecting the holistic evaluation of a learner and writing high-quality narratives that highlight both strengths and weaknesses. For the student’s benefit, using constructive feedback rather than only giving praise is the best method for motivational learning and enhancing future performance, leading to higher responsiveness and likelihood for change by the learner. From the perspective of a program director, when viewed over the longitudinal trajectory of a learner’s matriculation, both positive and constructive feedback paint a more comprehensive picture of the learner’s progress, improvement, or lack thereof; all of which are necessary and valuable when comparing applicants and judging a learner’s growth potential.  This becomes more important than ever with the USMLE moving to pass/fail scoring in the past two years, limiting quantitative data, making the other data such as the MSPE of greater importance. 

So how do we as evaluators do justice to both students and program directors in our narrative assessments? The more specific the feedback the better, particularly when given using descriptive language targeted toward actions and behaviors rather than judgment, personality traits, or assumption. Also, changing generic comments to those using assessment structured around core competencies can be more descriptive, specific, and more detailed. Finally, while your written assessment is crucial, it is also encouraged to give learners real time and in-person feedback, particularly when communicating concerns that will be documented in the narrative assessment. Additionally, including the student’s response to this feedback and their ability to appropriately self-assess provide an additional layer of valuable data to program directors. 

The limitations we have as educators based on time, energy, bandwidth, and availability are indeed real, but we owe it to our learners to do this well, considering they will soon be our future colleagues and eventually the physicians that will take care of each of us.