CanFamPhysician.2009Dec55(12):12601262.

PMCID:PMC2793234

Fieldnotes
Assistingachievementanddocumentingcompetence
MichelG.Donoff,MDCCFPFCFP
ProfessorintheDepartmentofFamilyMedicineattheUniversityofAlbertainEdmonton
Correspondence:DrMichelDonoff,1516049Ave,Edmonton,ABT6H5M8telephone7804920780fax7807354978email
mike.donoff@ualberta.ca
CopyrighttheCollegeofFamilyPhysiciansofCanada

ThisarticlehasbeencitedbyotherarticlesinPMC.

Clinicalpreceptorsremaincentraltotheenterpriseofsuccessfullyeducatinglearnersintheareasofprofessionalism
andclinicalcompetence.Theimportanceofapreceptorsroleisfurtherhighlightedaswesearchforcompetence
basedapproachestolearningandassessment.Competencebasedapproachesmustaddressthenecessaryskillsand
tasksspecifictoadisciplineorspecialty,1includingthosethatcannotbelearnedorassessedanywhereotherthan
theactualenvironmentsinwhichtheyarepractised.Medicaleducationrequiresexperientiallearning2thisfact
requirespreceptorstorolemodel,guide,andassesscompetence.Attemptstoimproveclinicaleducationarebest
directedtowardsupportingclinicalteachersandlearnersastheyworktogetherinclinicalenvironments.The
conceptoffieldnoteswasdevelopedspecificallyforthispurpose.
Background

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Fieldnotesarebriefdocumentsthatremindbothlearnersandpreceptorsthatobservationshavebeenmadeand
feedbackhasbeenprovided.Theyaredesignedtobegenericforconvenienceandversatility.Observationscan
rangefrominteractionswithpatients,interactionswithteammembers,discussionsofclinicalorprofessional
thinking,writtencommunication,learnerpresentations,andpsychomotororclinicalskills.Theytakelessthana
minutetocompletebutserveasamarkerthatclinicalcompetencehasbeenassessed.
Inthelate1980s,theDepartmentofFamilyMedicineattheUniversityofAlbertainEdmontonprinted
prescriptionsizednotepadsspeciallyformattedtoencouragepreceptorstobrieflydocumentobservedactionsor
eventsandsummarizethefeedbackprovided.Althoughtherehavebeenseveralvariationsprintedovertheensuing
years,thebasicfunctionremainsthesame.
Thechosennamefieldnoteisaveryclearreferencetotheintentionthatthesenotesbeusedandguidedby
referencetoqualitativemethodology.Qualitativemethods,specificallyparticipatoryactionresearchmethods,seem
toprovideausefulanalogyfortheprocessesinvolvedwhenateacherandalearnerworktogethertobuilda
meaningfulandtrustworthyunderstandingofthelearnersdevelopingcompetencies.3Likequalitativeresearch,
clinicalteachingisvalueladen,promotingchangethroughtheactofinquiry,encouragingparticipantstomutually
interpretallactionsandbehaviour,andgeneratingasenseofcoownershipoftheemergingnewunderstanding.
Formativeassessmentisdonewiththelearner,ratherthantothelearner.Thefocusofinterestchangesfrom
tryingtodetermineabinarystate,competentornot,toattemptingtounderstandthelearnershabitsof
competence.4Inessence,wearelessinterestedinthespecificskillsalearnerdemonstratesatagivenpointintime
andmoreinterestedinhisorherabilitytodemonstrateongoingandcontinuousimprovementthrougheffectiveuse
offeedbackandguidedselfassessment.
Preceptorshaveindicatedthattheyquiteclearlyappreciatewhenlearnersdoordonotexhibitthereassuringhabit
ofbecomingcompetent.Preceptorsreachimpressionsaboutlearnersnotfromobjectivemeasurementofknowledge
orskills,butratherfromrepeatedobservationofhowtheyaddresstheproblemsandneedsofpatientsandteam

members.Learnersfrequentlydemonstrategapsintheirknowledgeandskillsor,attimes,displaybehaviourthat
suggestsunhelpfulattitudes.Preceptorsrequestappropriatefacultydevelopmentandusefultoolsandprocessesto
addresslearnercompetencygaps.Theycorrectlyidentifyeffectiveandtimelyfeedbackasessential.
Ofsomeconcernisthatnumerouspreceptorsindicatetheyarepassingorpromotinglearnerswhodonotyet
demonstraterepeated,consistent,andhabitualbehaviourthatensuresongoingeffectiveapproachestobuilding
clinicalcompetenceandprofessionalism.Often,whenpreceptorsdonotseereassuringhabitsoflearning,they
continuetogivefeedbackonveryspecificandrandomobservations,butlackanorganizedapproachthatwillmove
feedbackanddiscussiontothehigherlevelsrequiredforattainingcompetence.
Toolstoassistpreceptorsandlearnersinaddressingthesehigherorderlevelsofcompetenceachievementare
invaluable.Therefore,wewilldescribesometipsandsuggestionsforusingfieldnotesin2phasesoffeedback:
dailyfeedbackwithlearnersanddocumentedfeedbackforongoingcompetencereview.
Fieldnotesfordaytodayfeedback

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Anecdotalevidencefrompreceptorsandadvisorsofresidentsconsistentlysupportstheideathatresidentsoftendo
notrecognizewhentheyarebeinggivenoralfeedback.Teachersareadvisedtoannouncethatfeedbackisgoingto
begivenwhenwishingtohelpimproveattention.Awrittennoteperformsthatfunctionpowerfully.
Fieldnotesshouldprovidepositivefeedbacklearnersneedpositivereinforcementaswellasconstructivecriticism
anddiscussalldimensionsandphasesofclinicalandprofessionalcompetence.Feedbackaboutclinical
encounterswithpatientsisimportant,butsoisfeedbackonhypothesisgenerationanddifferentialdiagnosis,data
interpretation,andmanagementplans.Also,notesshoulddiscusscommunicationskills(writtenandverbal),
learningapproaches,managementskills,and,ofcourse,professionalbehaviour.
Thevalueofanotedependslessonthedetailofobservationandmoreonthedetailoffeedback.Itisimportantto
beveryclearaboutsuggestionsforimprovementandskillstoreinforce.Timeandeffortcanbesavedbyavoiding
lengthydescriptionsoftheeventsthemselves.Usingafewwordstostimulatememoryofaneventissufficientthis
worksbestiffeedbackisprovidedsoonaftertheevent,asitshouldbeanyway.
Notescandeferdiscussionfromabusytimetolaterthatsamedayorwithinafewdays.Usethesimplestformatfor
notesavailableonepreceptorsreminderisanotherpreceptorsdistraction.Considerlettingthelearnerwritesome
notesidentifyingtheobserverandcapturingthereceivedfeedbackclearlydistinguishesthisprocessfrom
logbooks.
Fieldnotesforregularcompetencereview

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Manyprogramswantanorganizedandstructuredmethodforreviewingandtrackingalearnersprogresstoward
competence.Theplethoraofportfoliobasedprojects,articles,andconferencesattesttotheprevalentdesireto
addressthisneed.
Fieldnotescanbevaluableadditionsoreventhemaincontributortocompetencereviewdocuments,suchasin
trainingevaluationrating(ITER)forms.Evenwhenwedouseratingscales,asmostITERformsdo,weare
usuallysummarizingprogressforformativepurposesratherthanformakinghardlinesummativedecisions.The
valueofevaluationratingstoguidelearningplansandcurriculumdecisionsrestslargelyontheinputofdaytoday
interactionsbetweenthelearnerandthoseinhisorherclinicalsettings.Manyoftheproblemsassociatedwithusing
ITERformsstemfromusingthemasthefirstandonlycommunicationonlearnerprogress.
Learnersorpreceptorscanstackfieldnotestofocusattentiononchosencompetenciesorissues.Astackisa
groupoffieldnotes,whichidentifyatopic,competence,orprofessionalissuethatwouldbenefitfromongoing
feedback.Stackingfieldnotescanchangefeedbackfromrandomandisolatedtopurposefulwithcontinuity.Users
shouldconsiderwhensufficientprogresshasbeenachievedforatopicorwhetherthetopicremainsafocusof
activelearningsuchcompletedstackscanalsobeidentified.Discussionbetweenthelearnerandthepreceptoror
advisoraboutprogressusingstackednotescanbeanexcellentopportunityforguidedselfassessment.
Learnerspecificissuesshouldbeusedtonamestacksandsolicitfuturefeedback.Programlearningorevaluation
objectivesasreferencescanfocusfieldnotecollections(ie,stacks)anddirectattentiontodocumentedfeedback.

Singleentrydocumentationisvaluedwithalltypesofrecordkeepingincompetenceeducationitisefficienttouse
thesamedocumentationtorecordfeedbackandreviewprogress.
Eitherpaperorelectronicfieldnotesandcorrespondingreviewfolderscanbeused.Aswithelectronicmedical
records,thereisanupfrontdevelopmentcostforprovidingelectronicversions,butpreceptorsandlearnersare
easilymotivatedtouseelectronictoolswhenavailable.
Conclusion

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Fieldnotesaregeneric,userfriendlydocumentationtools,whichwereinitiallyintendedtoassistwithdaytoday
feedback.Inrecentyears,groupingnotesintostackshaspromotedfocusedandcontinuousfeedback.Evenmore
recently,objectivesexpressedasobservableattitudesandkeyfeatureshavefurtherpromotedaneffectivelearning
focus.Currentresearchisinvestigatingthecollectionandorganizationoffieldnotesinasystematicfashionto
allowtimelyandformativereviewofcompetencyprogressthroughoutaprogram.Collaborative,qualitative
principlesofinquiryremaincentraltoatrustworthycompetencebasedapproachtomedicaleducation.The
outcomeoftheseprocessesmightbesummarizedasguidedselfassessment.
TeachingMomentisaquarterlyseriesinCanadianFamilyPhysician,coordinatedbytheSectionofTeachers
oftheCollegeofFamilyPhysiciansofCanada.Thefocusisonpracticaltopicsforallteachersinfamily
medicine,withanemphasisonevidenceandbestpractice.Pleasesendanyideas,requests,orsubmissionsto
DrAllynWalsh,TeachingMomentCoordinator,atwalsha@mcmcaster.ca.
Notes

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TEACHINGTIPS

Usefieldnotestogivepositivefeedbackaswellasconstructivecriticism.
Usefieldnotestodiscussalldimensionsandphasesofclinicalandprofessionalcompetence.
Fieldnotesshouldfocusonsuggestionsforimprovementandskillstoreinforce,ratherthandetailed
observation.
Groupfieldnotesintostacksaccordingtotopics,competencies,orprofessionalissuesthatwould
benefitfromongoingfeedback.
Fieldnotescanbeappliedtocompetencereviewdocuments,suchasintrainingevaluationrating
forms.
Usetheprogramslearningobjectivesorevaluationsystemasareferencetofocusfieldnotestacksand
directattentionfordocumentedfeedbackandselfassessment.
Usesingleentrydocumentationandthesimplestformatofnotesavailable.
Electronicfieldnotesandcorrespondingreviewfoldersareencouraged.
Footnotes

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Competinginterests
Nonedeclared

References

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