Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study

Narrative feedback is the lifeblood of residency training. When a faculty physician writes comments on a resident’s performance, those words are supposed to chart the path toward clinical competence, track progress against the Accreditation Council for Graduate Medical Education’s six core competencies, and signal whether the trainee is reaching the milestones that govern modern, competency-based medical education. Yet for all its importance, feedback in graduate medical education has long been produced without any standardized instruction in how to do it well. A new interventional study from an internal medicine residency program affiliated with Wright State University Boonshoft School of Medicine and Wright Patterson Medical Center in Dayton, Ohio, now offers some of the clearest quantitative evidence to date that a modest, structured dose of education for both faculty and residents can measurably improve the quality of the written feedback residents receive.

The study, published in the Journal of General Internal Medicine by Rachel Cox, MD, and colleagues, was built around a deceptively simple question: if you teach the people who give and receive feedback what high-quality feedback actually looks like, does the feedback itself get better? To find out, the team implemented targeted educational interventions in 2022 and then compared the narrative assessments written before and after those interventions using a validated scoring tool. The results showed a statistically significant improvement in feedback quality, with mean scores rising from 2.48 to 3.37 on a 12-point scale, a change the authors describe as meaningful even though it also reveals how much room remains for growth.

The technical core of the study lies in how feedback quality was measured. The researchers collected narrative assessments and written faculty-to-resident feedback from resident feedback forms across two periods: the 2021 to 2022 academic year, before the intervention, and the 2022 to 2024 academic years, after it. All assessments were de-identified and then evaluated by two independent scorers using the Narrative Evaluation Quality Instrument, or NEQI, a tool developed to assess the assessor rather than the trainee. The NEQI quantitatively scores feedback across three categories: the performance domains commented on, the specificity of the comments, and the usefulness of the feedback to the trainee. Each assessment receives a total score ranging from 0 to 12, with higher numbers indicating higher quality. In total, 1206 narrative assessments met the inclusion criteria, 316 from the pre-intervention period and 890 from the post-intervention period, giving the comparison substantial statistical power.

The numbers tell a consistent story. The mean NEQI score increased from 2.48 before the educational workshops to 3.37 afterward, an improvement that reached statistical significance at P less than 0.001. The effect size was 0.5, which the authors characterize as moderate, suggesting the intervention is impactful rather than marginal. Perhaps most striking is the intraclass correlation coefficient of 0.92, an indicator of excellent interrater reliability. In practical terms, the two independent scorers agreed closely on how to rate both the pre- and post-intervention datasets, which strengthens confidence that the observed rise in scores reflects genuine improvement in the feedback itself rather than inconsistency in how it was judged.

The intervention itself was deliberately lean. Faculty members participated in biannual 90-minute interactive workshops covering the core principles of high-quality feedback, the common barriers to delivering it, and techniques for producing action-oriented comments. Residents, meanwhile, attended a single 60-minute workshop focused on deliberate practice, goal creation, and building expertise through feedback, with an emphasis on learners taking ownership of their own learning. Neither arm involved new technology, additional staffing, or sweeping curricular reform. The authors argue that this cost-effectiveness and relatively straightforward integration make the approach a scalable solution for other residency programs across various specialties, even though implementing such programs requires time and commitment from program leadership.

What makes the improvement technically interesting is that it emerged from education aimed at both sides of the feedback exchange. Prior research cited in the study has described the highest quality narrative feedback as specific, actionable, and constructive, and has emphasized that feedback should incorporate and be targeted to learner goals. The faculty workshops aligned with those best-practice components, teaching clinicians how to deliver effective comments. The resident workshop tackled the other half of the equation, encouraging trainees to seek feedback deliberately, set explicit goals, and treat feedback as raw material for deliberate practice. The literature has long noted that residents often describe seeking feedback as burdensome and anxiety producing, even though residents and faculty tend to agree on what constitutes effective feedback. The authors suggest their intervention may reduce those perceived barriers to engagement, bridging the persistent gap between intention and execution.

The study’s framing within competency-based medical education gives the findings broader significance. Under the ACGME milestones framework, feedback is not an optional courtesy but a mandated mechanism for achieving clinical competence and progressing through training. Inconsistent feedback quality can potentially impede residents’ progression and development toward clinical independence, which is why addressing the gap in feedback quality is framed as crucial to ensuring residents reach their milestones on schedule. By demonstrating that structured education can enhance feedback processes within this framework, the study provides program directors with an evidence-based lever they can pull without waiting for system-wide reform of how feedback is standardized across graduate medical education.

Even so, the raw scores carry a sobering message. The authors acknowledge that the average scores of both the pre-intervention and post-intervention groups are low overall on the NEQI scale, given that the maximum score, representing the highest quality feedback, is 12. A rise from 2.48 to 3.37 is statistically robust and practically relevant, but it also means that even after targeted education, the typical narrative assessment in this program still scored far below what the instrument defines as excellent. The authors point to prior descriptions of best practices, including specific, actionable, and constructive comments targeted to learner goals, as the direction in which feedback should continue to move, and they suggest that providing targeted education on how to deliver effective feedback could improve quality further, given the effect size observed here.

The study’s limitations are candidly stated. It examined only a single residency program and only a single year of residents across two specialties, which constrains how far the results can be generalized. The authors also note that the datasets generated and analyzed during the study are available from the corresponding author on reasonable request, and that the authors received no funding related to the manuscript and declare no conflict of interest. The research team, spanning Wright Patterson Medical Center, Wright State University Boonshoft School of Medicine, and Uniformed Services University in Bethesda, Maryland, included Kelsey Wilson, DO, Marc Gutierrez, MD, John Arthur, DO, Bryan Harper, DO, and Kathryn M. Burtson, MD, with contributions ranging from conception and design to analysis, interpretation, and critical revision.

For the wider world of medical education, the takeaway is both encouraging and demanding. The study demonstrates that targeted education on feedback significantly improves the quality of narrative feedback in an internal medicine residency program, making feedback more focused, specific, and valuable, and thereby contributing to optimal resident progression through training. A few workshops, delivered consistently to faculty and residents alike, shifted the measurable quality of more than a thousand written assessments in a statistically significant way. But the same data show that feedback across graduate medical education remains, by validated standards, far from excellent. The intervention offers a scalable starting point; the distance to the top of the NEQI scale defines the work that remains.

Subject of Research: Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study

Article Title: Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study

Article References: Cox, R., Wilson, K., Gutierrez, M., Arthur, J., Harper, B., & Burtson, K. M. (2026). Impact of Faculty and Resident Education on the Quality of Narrative Feedback in Residency: An Interventional Study. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10447-x

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10447-x

Keywords: Impact, Faculty, Resident, Education, Quality, Narrative, Feedback, Residency, Interventional, scientific research