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J Educ Eval Health Prof. 2014 Aug 13;11:17. doi: 10.3352/jeehp.2014.11.17. eCollection 2014.

Confounding factors in using upward feedback to assess the quality of medical training: a systematic review.

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Royal Bolton Hospital, Lancashire, United Kingdom.
North Western Deanery, Manchester, United Kingdom.



Upward feedback is becoming more widely used in medical training as a means of quality control. Multiple biases exist, thus the accuracy of upward feedback is debatable. This study aims to identify factors that could influence upward feedback, especially in medical training.


A systematic review using a structured search strategy was performed. Thirty-five databases were searched. Results were reviewed and relevant abstracts were shortlisted. All studies in English, both medical and non-medical literature, were included. A simple pro-forma was used initially to identify the pertinent areas of upward feedback, so that a focused pro-forma could be designed for data extraction.


A total of 204 articles were reviewed. Most studies on upward feedback bias were evaluative studies and only covered Kirkpatrick level 1-reaction. Most studies evaluated trainers or training, were used for formative purposes and presented quantitative data. Accountability and confidentiality were the most common overt biases, whereas method of feedback was the most commonly implied bias within articles.


Although different types of bias do exist, upward feedback does have a role in evaluating medical training. Accountability and confidentiality were the most common biases. Further research is required to evaluate which types of bias are associated with specific survey characteristics and which are potentially modifiable.


Bias; Confidentiality; Feedback; Quality control; Social responsibility

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