Table 3 Medical leads’ perceptions of their experience of providing feedback on written long cases, and their use of the eportfolio

Medical leads indicated they would prefer students to be given a more specific activity that reflects a real working situation for medical practitioners.

“I think every exercise has to have a point that you’re trying to teach and then we tailor the exercise – rather than say, oh, let’s just make them do a written and a verbal long case but why? What do we want them to learn from it?” (C 2)

“you present it to someone within 15 min ideally, but by the end of the day you find someone to present it to while it’s fresh, because that will teach them the recall factor, which is what it really is based on. It’s not about writing the perfect story or lecture or admission notes…. I think it’s very important to do it the day they do it…” (A1)

Quality of the feedback

Medical leads felt that the feedback provided on students’ written work was qualitatively different to that provided on verbal presentations. The written activity with written feedback allowed concentration on correcting the structure of students’ work.

Medical leads felt that written feedback provided via the e-portfolio may be more critical, honest and helpful than feedback provided by clinicians while they are busy on wards

Quantity of feedback

Medical leads felt that less frequent iterations of feedback were required by students

Additionally, medical leads felt that if fewer cases were marked, greater consistency in feedback could be provided, which would be valuable for students

Self directed learning

Medical leads felt the learning activity of performing long cases on the wards, forced students to be pro-active in their clinical placements, assisting students to be less hesitant in approaching patients, and also in approaching clinicians for feedback

Medical leads felt the written exercise with feedback helped to develop students’ verbal presentation skills.

“Written feedback is of course very different and I suppose you have to spend time thinking through how the student has structured their presentation and the structure and the content of the presentation and comment on that. So certainly takes a lot longer… They’re both very useful because you’re assessing different components of the students’ abilities”. (B2)

“When they were first starting, I would provide very thorough, long feedback, because initially, being new to this, they didn’t know what they were doing, and the structure was all wrong. So I’d actually show them the structure that they should follow, and, clarify what should go in what order, and explain what should be in an opening sentence, tell them if there was too much detail or too little detail, it depended on the student, and then always offer them to come and do one with me early on to get that straight before they went back”. (A1)

“I think the students need a combination of feedback. So …when you write it.. I would tell them if I think they really need to improve on something. But I can imagine that on the ward, in time pressures, that a lot of people go, “Yeah, yeah, that’s great,” and not actually give them any useful feedback. So I think written, and actually seeing, and, I always give an example of what I meant – so if I said, you know, “You should change it to be more like this,” I’d give them an example of an opening sentence from their case. So they see this is what should be in it. And a lot of people won’t do that if it’s an oral presentation because they are on the run”. (A1)

“The first lot, by the time I'd marked the long cases they'd already done three…. so the fourth one they tried to change to the way I had suggested in certain things so you could see an improvement …. but often (students uploaded) two or three at a time, at least two at a time”. (A2)

“Occasionally it would jump around (the structure), of course, depending on the flow. So they should still be able to master that order, and – and arrangement and plan orally, and then just write it down every second one or third one. So I don’t think it needs to be as many”. (A1)

“You needed to see their progression. And you could see the ones that weren’t progressing.…. in the recent form it was very beneficial to have the same (student) all the time, and then you can tell, yes, you’re getting better at this, this is great, this needs a bit of work. And by the end of it most of them were doing fine for a concise summary of a long case, how you do an admission in the notes”. (A1)

“I think there’s, um, there is a place for looking at students who are not improving over, say, the first four cases, there’s no sort of signs of improvement. And assigning those people to one person for the next two or three cases”. (C1)

“I think it’s a good thing because, the more practice you get the better and some students that are struggling or a bit more shy, it sort of forces them to, um, do the cases and get the practice in, um, and it’s certainly very good preparation for their exams.” (B2)

“Some take very well to immersion training, some are proactive, some become part of the team and engage with patients. There are many who just spend time on the rotation, and would only do things if invited to or if asked to do so. That second group is not insubstantial, they are a fairly large group of students….for a variety of reasons: feel shy, can’t communicate properly, maybe a less of a self-directed learning approach and more of directed learning approach is what they are used to. So for those sorts of students, setting the bar and saying, yes, you have to do one case every week is incredibly useful”. (B2)

“The usefulness of written presentation you could call it, is that it helps the student to develop a structure of where things should go and that in turn, could make, the verbal feedback easier in the long term”. (B2)

“…the students realise the value of the exercise, of – of having sequential long cases, and – I think the feedback that they’ve given is that it has been a very useful clinical exercise… the students have loved it. It’s been very well received. And what it does is, by the time they reached the end of Year 3, they have a sense of what a long case is all about. Which is exactly what this exercise is doing as well. I mean, that – that’s the whole point. So that they don’t hit Year 4 thinking, um, what is a long case?” (B1)

A major benefit noted by most medical leads was that the e-portfolio system provides a valuable way to systematically record and track students’ progress and identify students needing remediation

“I had access to everybody’s folders, that meant I could see who had or had not presented and keep an eye on who was lagging behind, so that we could give them a bit of assistance”. (C1)

“Having the longitudinal collation of cases – that’s a strength. It does work well… something that you do with students who are a bit weaker… you ask them to come back and present to you time and time again. Because if you pick up someone who’s not tracking well…a lot earlier. So I think it is very important… if someone’s just been terribly dismal…. despite feedback, they are not improving… you will often find that that student is weak in other areas too, and then you can bring them in and have a little chat to them about what their study technique or extra remediation exercises or whatever needs to be done. So it gives you a very good index of how – how the student is tracking”. (B1)

Technical barriers

Technical barriers were encountered by medical leads, who found the ePortfolio system to be cumbersome, and non-intuitive

Many of the students were not uploading their long cases consistently, negating the potential benefits of feedback and the opportunity to make improvements

Medical leads indicated they would like more interaction with the students to ensure their feedback is received and acted upon

“I found the system very frustrating - - - - - - and I almost quit because I found it so difficult to use”. (A2)

If I were to – to describe one major gripe, it’s the swapping of windows that you have to do when you’re editing a student’s work. You can’t sort of edit as you go along. You have to read it separately, and what I’ve been doing is printing it out often, um, reading it through once just to get a sort of flavour, and then going back and giving them feedback. So you just find that it’s quite time-consuming, I think. (B1)

“There was, a bit of a lag, where students sort of hoarded cases and then suddenly ran out and had to find a whole lot of people to present to…”(C1)

“The ones who kept on submitting and nothing changed - - - - - - and then I'd be writing, “just keep trying to follow this format” and then they would be – then I think some said, “well, I'd already written them all because I did the long cases 10 weeks ago and I'd already written them” - - And then just put them all up in one. (C2)

I never really knew if they read them or not read them - - - - or absorbed it or had questions because it, sort of, wasn’t as interactive as potentially the feedback could have been I think. (A1)

“There were maybe two who wrote back and said, “Yeah, no, that’s good,” and they asked questions and I definitely know that for them it was useful. But then for the – the vast majority who never communicated I don't know how much they took in”. (C2)