Field notes

Background

Field notes are brief documents that remind both learners and preceptors that observations have been made and feedback has been provided. They are designed to be generic for convenience and versatility. Observations can range from interactions with patients, interactions with team members, discussions of clinical or professional thinking, written communication, learner presentations, and psychomotor or clinical skills. They take less than a minute to complete but serve as a marker that clinical competence has been assessed.

In the late 1980s, the Department of Family Medicine at the University of Alberta in Edmonton printed prescription-sized notepads specially formatted to encourage preceptors to briefly document observed actions or events and summarize the feedback provided. Although there have been several variations printed over the ensuing years, the basic function remains the same.

The chosen name field note is a very clear reference to the intention that these notes be used and guided by reference to qualitative methodology. Qualitative methods, specifically participatory action research methods, seem to provide a useful analogy for the processes involved when a teacher and a learner work together to build a meaningful and trustworthy understanding of the learner’s developing competencies.3 Like qualitative research, clinical teaching is value-laden, promoting change through the act of inquiry, encouraging participants to mutually interpret all actions and behaviour, and generating a sense of co-ownership of the emerging new understanding. Formative assessment is done “with” the learner, rather than “to” the learner. The focus of interest changes from trying to determine a binary state, competent or not, to attempting to understand the learner’s “habits of competence.”4 In essence, we are less interested in the specific skills a learner demonstrates at a given point in time and more interested in his or her ability to demonstrate ongoing and continuous improvement through effective use of feedback and guided self-assessment.

Preceptors have indicated that they quite clearly appreciate when learners do or do not exhibit the reassuring habit of becoming competent. Preceptors reach impressions about learners not from objective measurement of knowledge or skills, but rather from repeated observation of how they address the problems and needs of patients and team members. Learners frequently demonstrate gaps in their knowledge and skills or, at times, display behaviour that suggests unhelpful attitudes. Preceptors request appropriate faculty development and useful tools and processes to address learner competency gaps. They correctly identify effective and timely feedback as essential.

Of some concern is that numerous preceptors indicate they are passing or promoting learners who do not yet demonstrate repeated, consistent, and habitual behaviour that ensures ongoing effective approaches to building clinical competence and professionalism. Often, when preceptors do not see reassuring habits of learning, they continue to give feedback on very specific and random observations, but lack an organized approach that will move feedback and discussion to the higher levels required for attaining competence.

Tools to assist preceptors and learners in addressing these higher-order levels of competence achievement are invaluable. Therefore, we will describe some tips and suggestions for using field notes in 2 phases of feedback: daily feedback with learners and documented feedback for ongoing competence review.

Field notes for day-to-day feedback

Anecdotal evidence from preceptors and advisors of residents consistently supports the idea that residents often do not recognize when they are being given oral feedback. Teachers are advised to announce that feedback is going to be given when wishing to help improve attention. A written note performs that function powerfully.

Field notes should provide positive feedback—learners need positive reinforcement as well as constructive criticism—and discuss all dimensions and phases of clinical and professional competence. Feedback about clinical encounters with patients is important, but so is feedback on hypothesis generation and differential diagnosis, data interpretation, and management plans. Also, notes should discuss communication skills (written and verbal), learning approaches, management skills, and, of course, professional behaviour.

The value of a note depends less on the detail of observation and more on the detail of feedback. It is important to be very clear about suggestions for improvement and skills to reinforce. Time and effort can be saved by avoiding lengthy descriptions of the events themselves. Using a few words to stimulate memory of an event is sufficient; this works best if feedback is provided soon after the event, as it should be anyway.

Notes can defer discussion from a busy time to later that same day or within a few days. Use the simplest format for notes available—one preceptor’s reminder is another preceptor’s distraction. Consider letting the learner write some notes; identifying the observer and capturing the received feedback clearly distinguishes this process from logbooks.

Field notes for regular competence review

Many programs want an organized and structured method for reviewing and tracking a learner’s progress toward competence. The plethora of portfolio-based projects, articles, and conferences attest to the prevalent desire to address this need.

Field notes can be valuable additions or even the main contributor to competence review documents, such as in-training evaluation rating (ITER) forms. Even when we do use rating scales, as most ITER forms do, we are usually summarizing progress for formative purposes rather than for making hard-line summative decisions. The value of evaluation ratings to guide learning plans and curriculum decisions rests largely on the input of day-to-day interactions between the learner and those in his or her clinical settings. Many of the problems associated with using ITER forms stem from using them as the first and only communication on learner progress.

Learners or preceptors can “stack” field notes to focus attention on chosen competencies or issues. A stack is a group of field notes, which identify a topic, competence, or professional issue that would benefit from ongoing feedback. Stacking field notes can change feedback from random and isolated to purposeful with continuity. Users should consider when sufficient progress has been achieved for a topic or whether the topic remains a focus of active learning; such “completed” stacks can also be identified. Discussion between the learner and the preceptor or advisor about progress using stacked notes can be an excellent opportunity for guided self-assessment.

Learner-specific issues should be used to name stacks and solicit future feedback. Program learning or evaluation objectives as references can focus field note collections (ie, stacks) and direct attention to documented feedback. Single-entry documentation is valued with all types of record keeping; in competence education it is efficient to use the same documentation to record feedback and review progress.

Either paper or electronic field notes and corresponding review folders can be used. As with electronic medical records, there is an up-front development cost for providing electronic versions, but preceptors and learners are easily motivated to use electronic tools when available.

Conclusion

Field notes are generic, user-friendly documentation tools, which were initially intended to assist with day-to-day feedback. In recent years, grouping notes into stacks has promoted focused and continuous feedback. Even more recently, objectives expressed as observable attitudes and key features have further promoted an effective learning focus. Current research is investigating the collection and organization of field notes in a systematic fashion to allow timely and formative review of competency progress throughout a program. Collaborative, qualitative principles of inquiry remain central to a trustworthy competence-based approach to medical education. The outcome of these processes might be summarized as guided self-assessment.