Factor Analysis Refines Feedback Tool for Teaching Informed Consent Skills

Obtaining informed consent is one of the first tasks a new surgical intern is expected to perform independently, yet many arrive in residency unprepared to do it well. A team at the University of Toledo College of Medicine and Life Sciences has now taken a statistical scalpel to the formative assessment tool that underpins its informed consent curriculum, mapping which of its twenty-two communication skills cluster together and which stand apart. The analysis, published in Global Surgical Education, identified three underlying constructs in student performance data: patient-centered engagement, diagnosis education, and procedure explanation. Together, these three factors accounted for just 20.91 percent of the variance in how students performed, a finding the authors interpret not as a failure of the tool but as evidence that informed consent is a genuinely multidimensional skill that resists compression into a short checklist.

The curriculum itself was built for graduating fourth-year medical students preparing for surgical-based residencies. Across two academic years, 2022–23 and 2023–24, a total of 325 students received the curriculum as part of their Transition to Residency course. It began with a ninety-minute didactic session on the principles of obtaining informed consent. Students then chose a medicine-based or surgery-based specialty track aligned with their matched residency focus and participated in a fifteen-minute encounter with a standardized patient, during which they were expected to obtain consent for a procedure relevant to that specialty. Immediately afterward, the standardized patient scored the student’s performance on a twenty-two-line-item communication skills tool, rating each skill on a scale from zero, meaning the skill was not demonstrated, through one for partial demonstration, to two for full demonstration. A five-minute feedback session followed, in which the standardized patient used the completed assessment to deliver targeted comments on strengths and areas for improvement.

The assessment tool deliberately balances eleven patient-centered and eleven procedure-centered communication skills. Its designers argue that this combination distinguishes their approach from existing informed consent assessments, which typically embed standardized tools within Objective Structured Clinical Examinations and base feedback on overall or generalized skill performance. To their knowledge, this is the first informed consent curriculum designed for students entering surgical residencies that combines standardized patient instruction, specialty-specific scenarios, and standardized-patient guidance with itemized formative feedback on specific consent skills. The motivation is practical: a survey by the Association of American Medical Colleges indicated that only half of participating residency program directors felt confident their postgraduate year-one residents could obtain informed consent without direct supervision, and other work has found that surgical residents fail to learn consent skills on the job as they progress from their first to their second year of training.

Earlier implementation of the curriculum had revealed a weakness. Students underperformed on certain skill items, and they scored significantly higher on procedure-centered communication items than on patient-centered ones. That pattern suggested the assessment tool itself could be refined, and the research team turned to exploratory factor analysis to do it. Factor analysis is a statistical method widely used in medical education research to uncover latent constructs within large datasets by examining correlations among original variables. It has previously proven useful for identifying highly correlated items on feedback forms, enabling assessment tool consolidation that improves feedback quality and shortens the time needed to deliver it. Principal axis factoring with Promax rotation was applied to the student performance scores, and the analysis was conducted in IBM SPSS Statistics Version 30.

The statistical groundwork was sound. Sampling adequacy was acceptable, with a Kaiser-Meyer-Olkin measure of 0.66 and a significant Bartlett’s test of sphericity, χ2(231) = 968.27, p < .001. Internal consistency of the full twenty-two-item tool was also acceptable, with a Cronbach’s alpha of 0.66. The initial extraction, using the Kaiser criterion of eigenvalues greater than one, yielded eight factors accounting for 57.1 percent of cumulative variance among the extracted factors, though these eight explained only 34.8 percent of the total variance, with factors five through eight each contributing a mere 1.5 to 3.0 percent. Given that limited contribution, those factors were excluded. Three- and four-factor solutions were then compared, and the scree plot showed an inflection point after the third component, supporting retention of approximately three factors.

The retained three-factor model told a nuanced story. The first factor had an eigenvalue of 3.09, corresponding to 11.10 percent of variance; the second had an eigenvalue of 1.93, or 6.20 percent; and the third had an eigenvalue of 1.48, or 3.66 percent, for a combined 20.91 percent. Items loading below 0.40 were excluded from interpretation. Factor one correlated with four skills: using language understandable to the patient, discussing expectations of the procedure such as length of hospital stay, activity restrictions, and return-to-work timeframes, discussing the benefits of the procedure, and checking for understanding. Factor two correlated with two skills, reviewing and verifying the history of present illness and past medical or surgical history, and exploring the patient’s knowledge of their condition. Factor three likewise correlated with two skills: exploring the patient’s perspective or thoughts about the recommended treatment plan, and treating the patient as a partner through shared decision-making. These mapped onto the dimensions the authors labeled patient engagement, diagnosis education, and procedure explanation.

The modest share of variance explained became the study’s most instructive result. In prior medical education studies, factor analyses of resident assessment tools identified factors explaining nearly 90 to 97 percent of the variance, suggesting that many skill items on those instruments were redundant and ripe for consolidation. Here, by contrast, each factor individually accounted for no more than 11 percent of variance in student performance. The authors conclude that consolidating the assessment tool on the basis of factor analysis may not be optimal. Given the exploratory nature of the analysis and the complexity of individual communication skills, they argue it was never realistic to expect a small number of factors to capture most of the variation. Instead, the low variance explained by a few factors suggests the assessment is not measuring a single construct but reflects multiple, independent elements of informed consent, all of which matter for feedback.

This interpretation aligns with a broader conception of informed consent as a dynamic process rather than the mere acquisition of a signature on a document, one that recognizes patients as individuals with unique goals and levels of understanding. The three identified factors reflect areas of the assessment tool showing greater internal consistency, and the authors propose using them as targeted areas for formative feedback rather than trimming the instrument. Retaining the tool in its entirety, they suggest, may preserve its educational value, while the factor structure can help identify patterns in student performance and guide individualized feedback. They also note that although a standardized, summative assessment will ultimately be needed to ensure final entrustment of Entrustable Professional Activities and residency readiness, the primary purpose of this formative assessment is to provide iterative feedback capturing the nuanced aspects of consent conversations. The factor analysis findings contribute preliminary evidence of internal structure validity, consistent with Messick’s framework, while the Cronbach’s alpha provides evidence of internal consistency reliability.

The analysis also sheds light on the standardized patients themselves, who serve as evaluators and feedback providers in place of scarce faculty time. The authors raise the halo effect, a cognitive bias in which one positive attribute of a person leads evaluators to attribute additional positive characteristics, producing inaccurate assessments and blurred distinctions between strengths and weaknesses. The numerous unloaded skill items and low variance explained by a few factors suggest the standardized patients in this study may have evaluated each skill independently rather than presuming competency across items. Ten standardized patients and trainers were trained by the senior author on the assessment tool and feedback principles before the sessions, and the authors propose further training on the targeted feedback areas identified in this analysis, combined with refinements to the didactic curriculum, as routes to narrowing the observed performance gaps.

The study has clear boundaries. The data came from a single academic medical center and only two cohorts of graduating students, limiting generalizability. Students were scored on a zero-to-two scale, chosen to enable uniform evaluation by standardized patients, which restricts variability compared with wider scales better suited to faculty raters. The authors also caution that the ordinal nature of the items should be considered when interpreting the exploratory factor analysis: the study used Pearson correlations treating the scores as numerical representations of increasing performance, whereas polychoric correlations designed for ordinal data might yield different item relationships and factor loadings. Future work will implement the refined curriculum and assessment tool and measure student performance afterward, and the team suggests the curriculum with standardized-patient-driven feedback could additionally be introduced during third-year surgical clerkships, where repeated practice could guide students toward mastery by graduation.

Subject of Research: Exploratory factor analysis of a formative assessment tool used in an informed consent curriculum for fourth-year medical students preparing for surgical residency

Article Title: Refinement of a formative assessment tool for an informed consent (EPA11) curriculum

Article References: Cash, C. A., Ren, G., & Hagopian, E. J. (2026). Refinement of a formative assessment tool for an informed consent (EPA11) curriculum. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 209. https://doi.org/10.1007/s44186-026-00621-4

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00621-4

Keywords: informed consent, EPA 11, formative assessment, exploratory factor analysis, standardized patients, medical education, surgical residency, communication skills, Transition to Residency, Cronbach's alpha, patient-centered communication, assessment tool refinement