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#KeyLIMEPodcast 191: Creating a risky recipe for learning

“Reconciling the tension between assessment’s focus on judgement and decision making and feedback’s focus on growth and development represents a critical challenge for researchers and educators.” Read on, and check out the podcast here.


KeyLIME Session 191:

Listen to the podcast.


Watling CJ, Ginsburg S. 2018. Assessment, feedback and the alchemy of learning. Medical Education. [Epub ahead of print]

Reviewer: Linda Snell (@LindaSMedEd)


There are dual purposes of assessment:

  1. Of learning: summative, decision making, for social accountability
  2. For learning: formative, to promote learning and development; this is becoming more prominent

Mixing the 2 is problematic, as their purposes seem at odds, and may ‘create a risky recipe for learning.’

This leads to tension between assessment’s focus on judgement and decision making and feedback’s focus on growth and development.


‘To synthesize the literature related to this tension, framed around four trends in education research:

  • shifting perspectives on assessment;
  • shifting perspectives on feedback;
  • increasing attention on learners’ perceptions of assessment and feedback;
  • increasing attention on the influence of culture on assessment and feedback.

To describe factors which produce and sustain this tension.’

Key Points on Method

Narrative review

‘Focus is on the clinical learning environment in medicine, draw on literature from across the medical  education spectrum, and on selected work from outside medical education.’

‘Literature on assessment and feedback is vast and varied, not attempted to be exhaustive in our coverage.’

Note: Narrative reviews consists of critical analysis of the literature to describe or discuss the state of the science of a specific topic; do not list the types of databases and methodological approaches used to conduct the review nor the evaluation criteria for inclusion of articles. Thus there is a potential for bias in source, selection and evaluation.

Key Outcomes

Assessment – the conversation

A concise history of the development over the past 70 years of attention to assessment, its division into formative and summative, its adoption into med ed, and the description of programs of assessment. Cites the classic papers (e.g. van der Vleuten, Norcini, Schuwirth). Raises the issue of low vs high stakes assessments, number of data points needed, etc.

Feedback – the conversation

Feedback, although championed since Ende’s paper, has only a modest effect on learning.

Describe the characteristics of effective feedback, and the threats to uptake of feedback.

Increasing importance of the learner-teacher relationship and the coaching model. Thus the challenge of dual roles of teacher as coach and as assessor, and the use of the same information for formative and summative purposes, creates tension.

Learner perceptions

Reviews recent research on how learners experience, integrate and use both assessment and feedback.

Learners blur summative and formative assessments – viewing one as other.

Learners are uncomfortable and ambivalent about direct observation, and may alter their performance.

Learners may perceive low stakes as high, especially if the know they must be successful at a number of them.

Cultural perspectives

The learning culture influences assessment; one focused on assessment may limit learners’ sense of safety to explore, experiment or fail.

Patient safety movement ‘opened the door’ for CBME, programmatic assessment, and WBA is a complex social interaction.

Our ‘niceness’ may be an impediment to honest feedback.

Entrustment scales used for feedback may contain messages that threaten self-esteem and identity, thus diminish feedback’s effectiveness. Whenever learners perform tasks with significance for their identity, assessment based on those tasks may feel summative, even if the intent is formative.

Suggestions to reconcile tensions

  • Need cultural and organizational support e.g.  one school:
    • clear expectations in the form of well-articulated competency standards;
    • frequent formative assessment;
    • strong learner support in the form of a faculty advisor for each student, and
    • learner responsibility, a learner-maintained portfolio.
  • Coaching, mentoring, academic advising, with resources provided for appropriate faculty development for those taking these roles.
  • Consider zero-stakes moments of learning, discovery and experimentation, e.g. simulation, coaching programs of direct observation.
  • Change the term from ‘formative assessment’ e.g. to coaching.

Key Conclusions

The authors conclude that “successfully blending assessment and feedback demands clarity of purpose, support for learners, and a system and organizational commitment to a culture of improvement rather than a culture of performance.”

We must be explicit about the purpose of a teacher–learner interaction, the intent of any assessment or teaching tool we use, and the consequences for the learner in relation to how he or she performs. We must embrace and routinely reinforce an improvement model of learning and of working, so that performing confidently is replaced by striving for improvement as a guiding professional value.

Spare Keys – other take home points for clinician educators

Great quotes:

‘Feedback is the catalyst that transforms assessment into learning.’

‘Stakes are in the eye of the beholder.’

‘Assessment may indeed drive learning, but it is not the only driver.’

‘. . . all actors in programmatic assessment must know what they are doing, why they are doing it, and why they are doing it this way.’ van der Vleuten


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