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Med Educ. 2020 Mar 9. doi: 10.1111/medu.14148. [Epub ahead of print]

Learning in the workplace: use of informal feedback cues in doctor-patient communication.

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School of Health Professions Education (SHE), Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6229 ER, Maastricht, the Netherlands.
Department of Obstetrics & Gynaecology, Amsterdam University Medical Center, Amsterdam, the Netherlands.
World Heart Federation, 1201, Geneva, Switzerland.
Respiratory Medicine, University Hospital, Goethe University, 60590, Frankfurt am Main, Germany.
Respiratory Medicine, Catharina Hospital, 5623 EJ Eindhoven, the Netherlands, and School of Health Professions Education (SHE), Maastricht University, 6229 ER, Maastricht, the Netherlands.



We expect physicians to be lifelong learners. Learning from clinical practice is an important potential source for that learning. To support physicians in this process, a better understanding of how they learn in clinical practice is necessary. This study investigates how physicians recognize and use informal feedback from interactions with patients in outpatient settings as learning cues to adjust their communication behaviours in daily practice.


To understand physicians' use of informal feedback, we combined non-participant observations with semi-structured interviews. We enrolled 10 respiratory physicians and observed 100 physician-patient interactions at two teaching hospitals in the Netherlands. Data collection and analysis were performed iteratively according to the principles of constructivist grounded theory.


Following stages of open, axial and selective coding, we were able to conceptualize how physicians use cues to reflect on and adjust their communication. In addition to vast variations within and across patient encounters, we observed recurring adjustments in physicians' communication behaviours, in reaction to specific informal feedback cues. Physicians recognised and used these cues to self-monitor communication performance. They had established a 'communication repertoire' based on multiple patient interactions, which many saw as learning opportunities, contributing to the development of expertise. Our findings, however, show differences in physicians' sensitivity to recognise and use learning opportunities in daily practice which was further influenced by contextual, personal and interpersonal factors. Whereas some reported to have little inclination to change, others used critical incidents to fine-tune their communication repertoire, while others constantly reshaped it, seeking learning opportunities in their daily work.


There is a large variation in how physicians use learning cues from daily practice. To enhance learning in and from daily practice, we propose turning workplace learning into a collaborative effort, aiming at increased awareness and use of informal performance relevant feedback.


Communication skills; Continuing Medical Education; Professional Development; Qualitative Research Methods


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