In 2000, the Accreditation Council for Medical Education introduced a new initiative that substantively changed the method by which residency programs are evaluated. In this new competency-based approach to residency education, assessment of performance became a main area of interest, and direct observation was offered as a tool to assess knowledge and skills. Despite being an inherent part of medical education as faculty and learners work together in clinical experiences, direct observation has traditionally been an informal and underused assessment method across all specialties. Residents and students report rarely being observed during their educational process, even though they value the experience. Reasons for this include a lack of faculty time, a lack of faculty skills, a potential stressful effect on the learner, and a perceived lack of validation of the assessment. This article examines the literature regarding the use of direct observation in medical education with a focus on validity evidence. We performed a PubMed search of articles pertaining to direct observation, using key words such as direct observation, performance observation, clinical observation, students, and residents. A subsequent search was conducted in known articles, focusing on variations of the term observation in the titles of articles and introducing the concept of clinical competence. In conclusion, direct observation is a unique and useful tool in the assessment of medical students and residents. Assessing learners in natural settings offers the opportunity to see beyond what they know and into what they actually do, which is fundamentally essential to training qualified physicians. Although the literature identifies several threats to its validity as an assessment, it also demonstrates methods to minimize those threats. Based on the current recommendations and need for performance assessment in education and with attention paid to the development and design, direct observation can and should be included in medical education curricula.

Background Despite the importance of feedback, the literature suggests that there is inadequate feedback in graduate medical education. Objective We explored barriers and facilitators that residents in anesthesiology, emergency medicine, obstetrics and gynecology, and surgery experience with giving and receiving feedback during their clinical training. Methods Residents from 3 geographically diverse teaching institutions were recruited to participate in focus groups in 2012. Open-ended questions prompted residents to describe their experiences with giving and receiving feedback, and discuss facilitators and barriers. Data were transcribed and analyzed using the constant comparative method associated with a grounded theory approach. Results A total of 19 residents participated in 1 of 3 focus groups. Five major themes related to feedback were identified: teacher factors, learner factors, feedback process, feedback content, and educational context. Unapproachable attendings, time pressures due to clinical work, and discomfort with giving negative feedback were cited as major barriers in the feedback process. Learner engagement in the process was a major facilitator in the feedback process. Conclusions Residents provided insights for improving the feedback process based on their dual roles as teachers and learners. Time pressures in the learning environment may be mitigated by efforts to improve the quality of teacher-learner relationships. Forms for collecting written feedback should be augmented by faculty development to ensure meaningful use. Efforts to improve residents' comfort with giving feedback and encouraging learners to engage in the feedback process may foster an environment conducive to increasing feedback.

Residents serve as critically important teachers of students in the clinical workplace. Current RAT models are based largely on the teaching behaviors of faculty. The content and teaching strategies identified by students in this study should serve as the foundation for future RAT program development.