Twelve tips for creating and sustaining a peer assessment program of clinical faculty

Abstract While feedback is essential for learning in the health professions, clinical teachers rarely get feedback on their teaching, and the existing feedback is often non-specific and distant from teaching encounters. To enhance clinical teaching, we created a peer assessment program for clinical faculty. This program has been well-received and sustained for five years despite the challenges of faculty turnover and the pandemic. In this article, we identify twelve tips for creating and sustaining a peer assessment program for clinical faculty based on this experience. These tips focus on how to create a culture that supports peer assessment, on how best to implement a peer assessment program in practical terms, and on how to sustain a peer assessment program long-term. We hope these tips help educators receive better feedback about their clinical teaching and improve the future care delivered by our learners.


Introduction
Feedback is essential for improvement (Kolb 1984).Throughout medical training, learners rely on formative feedback to improve their clinical skills.Educators observe their performance, assess competence, and provide specific feedback on both behaviors that are done correctly and those that need to be improved upon.Done well, feedback should be given close to the observation so that the performance is fresh in the mind of the trainee, and specific behaviors are identified that can be altered through a collaborative plan for improvement.Feedback appears to be the most important aspect of learning in many settings.
However, clinician educators rarely receive feedback on their teaching.Learners fill out evaluations of teachers, but these evaluators are not trained experts, and, to protect students and preserve anonymity, evaluations are reviewed with faculty well after learner-teacher interactions occur.Because of these factors, this feedback lacks the specificity and timeliness needed for educators to improve as much as possible.Learners may also be afraid to make honest observations.We need a better approach to improve the work of clinical teachers.
One approach is peer evaluation of teaching by other clinical educators.Peer assessment is a valid and reliable approach but must be carefully constructed (Kane & Lawler 1978;Norcini 2003).Peer assessment has been successfully implemented with medical students and in simulated teaching scenarios (Finn and Garner 2011).Peer assessment has had some small, demonstrated successes with clinical educators though these reports also note challenges with implementing and sustaining these programs (Pedram et al. 2020;Shaines & Cassese 2022;Stockdill et al. 2023).
In order to help faculty interested in developing a peer assessment program of clinical teaching, we identified twelve tips to help implement and sustain a program.These tips stem from a five-year, collaborative experience of creating and engaging in a peer assessment program within a division of hospital medicine.The program continues to operate despite the challenges of faculty turnover and the COVID-19 pandemic.

Embrace feedback as essential to better teaching
While the benefits of feedback are well known, busy providers may not embrace receiving feedback from peers.Hesitation may stem from feeling self-conscious or from fears of being judged.This is especially true if faculty struggle with feelings of imposter syndrome, feelings of being inferior to peers (Shanafelt et al. 2022).Notably, impostor syndrome afflicts physicians more commonly than other professionals.In addition, receiving feedback may be something physicians are unaccustomed to, especially senior physicians who are more removed from medical training.To overcome resistance to receiving feedback, educators should create a culture that embraces feedback.Leaders should seek to allay concerns about receiving feedback by having open communication about implementing a peer observation program.Faculty should have opportunity to ask questions about the program.For example, introduce the program to your faculty at a staff meeting or grand rounds where you explain with transparency the motivation behind the need for feedback and how it will help them.Emphasize the value of feedback at all levels of one's career.In addition, the program should be voluntary and piloted with the most willing participants who can help normalize the feedback and express what they learned from the observation and feedback session.Senior faculty and leaders can be important boosters of the program in this way.a few passionate participants can help the rest of the faculty truly embrace the need for feedback.

Separate feedback from faculty performance reviews
Peer observation programs should provide formative feedback necessary to improve clinical teaching, and it is essential to clearly define this as its purpose.To get the most out of an observation, the teacher needs to feel relaxed and free to perform as if the observer was not present.This is difficult if the teacher feels like they are being graded or if the observation is tied to job performance.Observation by a peer who assesses teaching strategies and provides advice on how to improve is most helpful when the experience does not lead to increased anxiety for the observed.Feedback sessions should be conducted as a low-stakes conversation between colleagues.It is essential for the teacher to know that the observation does not carry with it the threat of decreased teaching time or a poor rating on annual teaching reviews, which could affect promotion.In this regard, it may be better that physician supervisors (I.e., chairs or chiefs) do not conduct peer observations.

Create expectations around observations
Defining an expectation that all clinical teachers be observed promotes a growth-mindset by acknowledging that even the most senior teaching faculty need feedback to improve.If everyone is observed, the anxiety surrounding the observations decreases because faculty know they are not being targeted for a specific reason.Frequent evaluations normalize the experience, getting people in the habit of wanting feedback.Teachers may realize that they benefit from having someone observe them as they try a new method of teaching, and excitement for a repeat observation can increase.Junior faculty benefit from the reassurance in their teaching abilities, while more senior faculty may be grateful to be given the feedback they may not have received for many years.Once observations begin, most faculty recognize how helpful getting feedback on teaching sessions can be.In addition, teachers who are observed may develop interest in having the opportunity to observe colleagues.The value of peer observation extends from the teacher observed to the observers who experience different approaches used by peers.As the program grows, new faculty may observe more experienced faculty before their first assignment working with learners to orient them to the role of and some approaches to clinical teaching.Creating a process for which anyone can request to observe a peer improves the buy-in to your program.

Select or create a tool that fits your goals
A crucial decision is deciding on a tool to structure the observations.The following factors should be considered: What behaviors do you want to encourage in your teachers?Do you wish to provide strictly qualitative or quantitative feedback?How much detail do you want to collect about each behavior?Do you simply want to note if a behavior was observed or not during the session, the frequency the behavior was exhibited, or the competency of the teacher in performing that behavior?Is there other information you would like to record about the teaching session outside of teaching behaviors?Potential data points include the duration of the observation, the location of the observation (table rounds, in the hall, or at the bedside of the patient), the number of patients seen/discussed during the observation, and the number and/or types of learners present for the observation.While several tools have been used for peer observations, the tool should have clear instructions and be succinct (Pedram et al. 2020;Shaines & Cassese 2022;Stockdill et al. 2023).The observer should be able to quickly scan the tool for demonstrated behaviors and have a straightforward way of recording data, such as checkmarks, to notate completion of a behavior.The tool should be in a format easiest to use for your clinical scenario, whether it be a paper copy, an electronic document, or a web-based application.While quantitative data can be useful and straightforward to implement, we have found that the tool should allow room for comments for feedback to the observer as these are often the most valuable aspects of feedback.Lastly, the tool should include a space for review and documentation of self-reflection by the teacher.As an example, our group's current observation tool is available for review in the Supplementary Appendix.

Identify and train observers
Consistency among observers is a necessity for any peer observation program.To achieve consistency, a group of faculty members experienced in bedside teaching should be selected.Observers should be enthusiastic about teaching, respected by the teaching group, and not in a formal supervisory role.They should seek to be objective in their comments and able to deliver feedback in a non-intimidating fashion.Observers will have the opportunity to critically appraise a colleague's approach to teaching and fostering an effective learning environment.This experience is unusual in health professions education, and observers should embrace this opportunity as important for their own professional growth.The observers should then be trained in how to complete the observation tool.A method for insuring consistency is to watch a recorded bedside encounter of a teacher with learners.Have the group of observers complete the tool based on their observations then discuss similarities and differences in scoring among the group members.This will enable the group to achieve a consensus on how best to record observations and how to use common language in feedback comments (Newman et al. 2016).Another approach is to conduct joint observations of a teaching encounter in the clinical setting.While this approach has the benefit of multiple perspectives of feedback, it also increases the number of observers which can be both intimidating and impractical.

Organize observations in a way that promotes sustainability
Longer observations or those with multiple observers do not necessarily provide the observer with more information about the teacher.We have found that decreasing the length of observations from 60-90 min to 45 min still resulted in thoughtful feedback for the teacher.To avoid missed observation opportunities, it helps to schedule observations on days when the observer is already at the hospital for other reasons, such as administrative duties or while on a flexible clinical shift.It also helps to keep the observation schedules flexible, ensuring that there are multiple available opportunities for both teacher and observer and a contingency plan for rescheduling or for a back-up observer.We favor limiting observations to one observer at a time.While missing some multi-dimensional aspects of feedback, having one observer supports sustainability and decreases intimidation.One reported peer observation study (Mookherjee et al. 2014) noted a sharp decline in the number of observations over time when they required two observers for each interaction; removing the dyad requirement made the observations more flexible and resulted in more faculty buy-in.

Prepare the person being observed
The teacher should be oriented to the observation well before the teaching encounter and again at the start of the observation.We recommend providing faculty with an orientation to the observation process at the start of each academic year.This initial orientation should include the reasoning behind the observation, the goals for the observation, and an overall summary of the observation process.The group should be allowed to ask questions during this orientation and any concerns should be addressed.Creating this culture is essential for sustainability.Then, approximately a week before a teacher is to be observed, we recommend sending a reminder email to the teacher and the observer.The email should include the structure of the observation, the information about the exact date and time of the observation, reassurance that the observation is for faculty development only, and a copy of the observation tool.The email should also include a reminder that the teacher should not change their rounding style to minimize the Hawthorne effect (Sedgwick and Greenwood 2015).Prior to the observation, it may be beneficial for the observer to ask the teacher if they would like feedback on anything specific; this directs the observer's attention to those teaching behaviors.Both the teacher and observer should be encouraged to ask clarifying questions, and teachers should be allowed to delay the observation if they are not yet comfortable being observed.

Orient the learners to the observer role
At the start of the observation, the observer should introduce themselves to the teachers' team of learners and explain their role.The observer should clearly say that they will be observing the teacher's behaviors and not evaluating the learners so that the observer's presence minimally alters the dynamic of the team and the behaviors of learners.The observer should emphasize that they will only observe rounds; they will not interrupt bedside rounds or interact with the team to teach or provide opinions on clinical decisions.Quiet observation lowers the anxiety of the teacher and may make them more likely to engage and interact with their learners in their typical fashion; it can also minimize the Hawthorne effect (Sedgwick and Greenwood 2015).Setting these expectations for the teacher and learners helps the peer evaluation be successful and sets a positive example of attendings accepting peer feedback and engaging in life-long learning.

Keep the feedback session simple
Feedback is most effective when it is clear, concrete, focused, and delivered in small portions.Communicating in a variety of ways can help with comprehension and reflection (Brinko 1993).We provide both verbal and written feedback.The verbal feedback is done in a face-to-face or phone-call session between the observer and teacher shortly after the observation is completed.In addition, the teacher also receives written feedback via the completed observation tool.We use our feedback tool to identify what behaviors the observer noted and did not note during the observation session.We encourage the teacher to reflect on what went well and what could be improved.One study (Schum and Yindra 1996) noted that a similar simple feedback model was both time efficient and effective, leading to higher ratings in several teaching traits.In contrast, we have found that adding more activities to the feedback session, such as asking teaching attendings to establish goals, unnecessarily complicated the experience.Discussing goals and then trying to follow up on them in later observations proved to be logistically difficult for our group.While discussing the teacher's goals for their personal faculty development may be an enriching activity during the feedback session, simplicity and flexibility are essential.

Re-evaluate the observation program at regular intervals
Sustaining a peer observation program depends on ongoing evaluation and refinement.The program should continue to provide benefit to the faculty being observed, should integrate effectively with other professional obligations of the faculty who are observed and are observing, and should align with overall education goals of the unit and the organization.All aspects of the program-who is observed, who are observers, what tool is used, how the observations are conducted, and how feedback is givenshould be reviewed as goals may evolve.Feedback from the observers and the faculty observed should drive change along with trends in teaching behaviors noted on the evaluation tool.For example, we have modified our tool several times removing behaviors demonstrated by all teaching faculty during every observation and clarifying or splitting other behaviors into multiple separate items.We have also decreased observations of more senior faculty and integrated observations into the onboarding of new teaching faculty.In addition, external circumstances, like a global pandemic, may necessitate change.

Tip 11 recognize the efforts of the observation team
While a peer observation program promotes an academic culture, formal recognition of the program and observation efforts is important.The specific strategy for recognition depends on the broader approach the academic unit takes towards encouraging educational professional engagement.We have integrated being an observer into our framework for incentivizing academic work.Other institutions should advocate for inclusion of participation in this program in whatever system they use to measure and encourage academic productivity (Stites et al. 2005).In addition, taking part as a peer observer shows interest in being a faculty teacher and should be a marker of who might become a future educational leader (Clyburn et al. 2011).

Share the lessons learned
The observation team learns many educational skills while performing observations.Seeing a diversity of teaching styles provides the faculty with exposure to a wide breadth of approaches, enriching the individual observer's teaching while also serving as a source of knowledge that should be further disseminated.The team should share these insights with each other as they seek to build a community of practice around better clinical teaching (de Carvalho-Filho et al. 2020).Not only does sharing lessons learned in regular meetings and frequent email communications enhance everyone's observations and teaching, it also supports the sustainability of peer observation efforts.These lessons may be of interest beyond the team of observers.Other faculty of the academic unit may be interested in trends and insights from the peer observation process.Findings may be disseminated externally through presentations in external venues and peer-reviewed publications.Clinician educators are usually passionate about being excellent teachers and bring their unique identities into teaching (Palmer 1998), allowing opportunities for colleagues to gain new perspectives.Through a peer observation program, they can create scholarship aligned with their passion for excellent teaching.

Conclusion
Peer assessment of clinical teaching is an emerging way to enhance education in healthcare.Implementing and sustaining a peer assessment program requires collaboration and forethought.Through these tips, educators can create a culture to support peer evaluation, overcome the logistical challenges that can hinder peer evaluation, and engender the momentum needed to sustain a program long-term as we seek to enhance our teaching and the quality of care of our learners.