From Value to Valued: International Medical Students' Changing Views on Feedback Perception and Application in Communication Learning

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Eleonore Köhler, Maryam Asoodar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7426383/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Introduction This study explores the evolution of first-year international medical students' perceptions of feedback as they develop communication skills through simulated patient consultations (SPCs). Knowing how students’ appreciation of feedback evolves over time is essential for improving feedback methods in medical education. Methods In this qualitative 36-week study, we followed ten students, collecting data through closed questions assessing feedback perception, observation notes, and semi-structured interviews to document students' emotions and subjective reactions to feedback. Results The findings indicate a gradual change in the importance students place on various feedback during their SPCs. Initially, feedback from simulated patients was highly valued due to its direct relevance to patient interactions and the students' focus on reducing their learning load. Data analysis revealed that as students progressed in their studies, the frequency of students using student-buddy feedback increased. By the final SPC, students reported that tutorial discussions had become their most trusted and reliable source of feedback. The analysis of the interviews also revealed four predominant themes that shed light on why their perceived values of feedback changed over time: navigating through stress, adapting to the challenge, enhancing the learning efficiency, and listening to the full story. Discussion The study reveals how medical students' views on the value of feedback evolve through simulated patient consultations, initially valuing patient feedback, then shifting to peer insights, and eventually to tutorial discussions. This progression reflects the students' growing skills in communication and their adaptation to the challenges of SPCs. The findings emphasize the importance of tailoring feedback strategies to the students’ developmental stages in medical communication learning during consultations, thereby enhancing the acquisition and retention of these skills. More broadly, this study underscores the critical role of adaptive feedback mechanisms in professional education, suggesting that such tailored approaches could be beneficial across various disciplines where skill development and effective communication are essential. simulated patient consultations student-buddy feedback simulated patient feedback video annotation feedback tutorial discussions Figures Figure 1 Figure 2 Introduction Effective communication is a cornerstone of quality healthcare, and its development during medical education is critical ( 1 , 2 ). Feedback plays an essential role in this development by providing medical students with the necessary insights to refine their communication skills ( 3 ). Given the importance of feedback, various methods have been explored to enhance its effectiveness in medical education. One such method is the use of Simulated Patients (SPs), which has been extensively studied and recognized as a valuable method for enhancing communication skills ( 3 , 4 ). Simulated patient consultations (SPCs), a teaching method in which students interact with trained actors simulating real patients, provide a controlled yet realistic environment for students to practice and refine their medical communication skills ( 5 – 9 ). These studies highlight the importance of feedback within the context of SPCs in improving medical students' communication abilities and the process of making sense of feedback ( 9 , 10 ). Feedback is crucial for medical students' skill development and professional growth( 11 ). However, as students gain clinical experience, their perceived value of feedback nuances can evolve over time. This reflects shifting needs in learning, improved feedback interpretation, and a deeper understanding of feedback’s role in professional growth ( 12 ). Despite the recognized importance of feedback in medical education, there is a significant gap in research regarding the evolution of students’ perceptions of its value throughout their medical communication training. Understanding how learners perceive, and shifting their attention to different sources of feedback can greatly inform the design of more effective feedback strategies, ultimately enhancing the educational experience. Cognitive load theory offers a valuable framework for understanding how students process information and learn most effectively ( 13 , 14 ). It emphasizes that the human cognitive system has limited capacity for processing new information, and instructional design should aim to optimize this capacity by managing cognitive load. This involves managing the natural difficulty of the material (intrinsic load), avoiding unnecessary complications (extraneous load), and supporting the development of lasting knowledge and skills (germane load) ( 15 ). Effective feedback can reduce the intrinsic learning loads in tasks ( 16 , 17 ), helping students identify and correct misconceptions ( 18 ). Peer feedback, for instance, has been shown to lower extraneous cognitive load by providing relatable, actionable insights from learners at similar developmental stages ( 19 , 20 ). The cognitive load theory also helps direct attention to the most crucial aspects of learning tasks, optimizing cognitive resources ( 21 ). Drawing from the theory, research finds that clarifying the accuracy of students' understanding enhances their sense-making process of feedback, thereby streamlining cognitive processing and enhancing overall learning efficiency ( 13 , 15 ). In alignment with these principles, simulated patient consultations provide a safe, authentic environment that enhances feedback quality, reduces cognitive load, and improves learning outcomes ( 3 , 4 , 13 ). For example, structured peer feedback during SPCs can help students prioritize actionable improvements, whereas simulated patient feedback often highlights experiential nuances (e.g., nonverbal communication) that peers might overlook ( 3 , 6 , 22 ). By applying cognitive load theory to the design of SPCs, students’ strategy in engaging in independent problem solving, for example makings sense of feedback, and using feedback information becomes more comprehensive and cognitively manageable, thus supporting students in their journey to become proficient medical communicators. While feedback is known to be essential for student learning, less is understood about how students perceive the value of feedback at different stages of learning. This study aims to explore how students perceive the value of feedback and how this perception evolves as they progress through SPCs and gain more experience in interpreting and applying feedback to improve the quality of their medical communication consultations. Research Questions: How does the perceived value of feedback (from buddies, simulated patients, video annotations, and tutorial discussions) evolve as students’ progress in their SPCs? How does the students’ perceptions of their learning process in Simulated Patient Consultations evolve as students' perceptions of the value of feedback from various sources (buddies, simulated patients, video annotations, and tutorial discussions) change over time? Methods Research Team and Reflexivity: The research team was a collaborative ensemble, featuring three medical education experts—J.v.M., S.E.K., and M.A.—each with a substantial background of over eight years in their respective areas of expertise. Together, they pooled extensive knowledge in medical education and instructional design research. Strengthening this core team were two PhD candidates, H.Y. and Z.L., who contributed three years of practical experience in medical education, enriching the study with their distinct viewpoints. H.Y., and M.A., adept in qualitative research methodologies, provided valuable insights particularly relevant to research and instructional design in simulated patient consultations. Z.L. and M.A. lent their expertise in thematic analysis and brought firsthand experience with educational interventions in healthcare settings. Additionally, M.A., J.v.M., and S.E.K. enriched the study by offering theoretical perspectives and critical insights, contributing to the research's comprehensive scope. Setting of SPC In our setting, we applied Cognitive Load Theory (CLT) to guide the design of high-fidelity learning environments that optimize medical students' learning experiences during Simulated Patient Consultations (SPCs). The SPC utilized a three-phase model to structure consultations. This model provides a comprehensive and transparent framework for both complaint-centered and follow-up consultations, helping medical students integrate patient-informed and medically informed pathways( 23 , 24 ). Phase one, focuses on clarification of the reasons for the encounter. Phase two, involves extended history taking and physical examination. Phase three, centers on explanation, dialogue, planning, and closing the consultation. Students prepared for their SPCs in a skills lab equipped with consultation desks, examination beds, and sanitary systems. Additionally, to a medical consultation setting, video recording equipment was installed in the corner of the consultation room which aimed to record students’ SPC and to upload it to the eLearning platform. Each SPC session involved three participants: one student-doctor, one student buddy (observer), and one simulated patient. The student buddy, a peer learner from the same course, acted as an observer to systematically assess the student-doctor’s performance during the SPC, providing first-person feedback that enhanced learning and skill development ( 25 ) Design of SPCs SPCs were designed to manage intrinsic load by maintaining consistent complexity levels, focusing on one medical condition per session, and providing feedback and guidance through an eLearning platform and tutorial discussions. To minimize extraneous load, the consultation room was equipped with necessary tools, video recording equipment was used to capture sessions, and roles were clearly defined. Germane load was enhanced by incorporating multiple feedback sources, including student-buddy, simulated patient, and video annotation feedback, which supported schema development and long-term learning. Feedback included tips for improvement and points of pride, and students were encouraged to reflect independently before tutorial discussions to enhance learning outcomes. Before the SPC began, the student-doctors prepared themselves in the consultation room, dropping bags, engaging in small talk and relaxing, and familiarizing themselves with their learning objectives. At the beginning of each SPC, the student-doctor and student buddy conducted a brief preparation session. The student-doctor outlined their learning goals and the focus areas for the consultation, while the student buddy initiated the recording system. This self-directed briefing ensured both participants were aligned and prepared for the session. Meanwhile, the simulated patient waited outside the consultation room, ready to be called in. Once the student-doctor was ready, they began the SPC by inviting the patient into the consultation room. Figure 1 illustrates an ongoing SPC, where one student took on the role of the doctor while their student buddy observed from a corner of the room. The student buddy closely monitored the student-doctor’s performance, tracking whether the learning objectives were met and noting areas for improvement. This observation allowed for a detailed examination of each stage of the consultation. The consultation was conducted with a trained simulated patient, who presented a complaint similar to that of a real patient. Upon the consultation's conclusion, the first form of feedback exchanged was student-buddy feedback. The student buddy provided observations and informal feedback regarding communication. Throughout the course, students alternated between the roles of student-doctor and student buddy to ensure each participant experienced both perspectives. Following the student-buddy feedback, simulated patient feedback was provided. Simulated patient feedback was typically unstructured, with the basis of the feedback focusing on the questions the students asked the simulated patient. For instance, it included feedback on the clarity of sentences and the engagement of both verbal and non-verbal communication. Post-SPC Reflection and Video Annotation Feedback provided by the tutor and the peers After the SPC, the video recording of the consultation was uploaded to the University Learning Space, an online learning platform. The students and tutor had access to these recorded consultations and gave annotated feedback at specific points in the video. The timing of the feedback was not predetermined; instead, students and the tutor provided feedback a few days before the group discussion session. This allowed students ample time to familiarize themselves with and reflect on the annotations before the course. The video annotation feedback was designed to be balanced, incorporating both positive and critical elements. Students and the tutor gave positive feedback to highlight strengths, such as effectively demonstrating empathy or successfully delivering complex medical information. On the other hand, they provided constructive feedback that offered actionable suggestions for improvement, such as refining communication strategies or offering clearer medical explanations. Students were expected to review and reflect on the feedback they received through the annotations independently before the tutorial discussion sessions. This independent reflection was intended to help them identify areas for improvement and prepare for the group discussion. Unresolved or unclear feedback points are brought to the tutorial discussion sessions for further clarification. Follow-up Tutorial Discussions Roughly, a week after the SPC, all students gathered for a Tutorial Discussion with the whole class of 10 students and their tutor. During this session, individual SPC performances were reviewed, and feedback from the video annotations, student-buddy feedback, and simulated patient feedback were discussed in depth. With the tutor’s guidance, each student sets specific learning goals for the future to ensure they focus on areas for improvement. These face-to-face interactions provided the opportunity for the students to ask questions, seek clarification, and engage in group reflections on their learning goals and progress. Research design In this study, we employed a qualitative approach to examine the development of students' medical communication skills and how their perceptions of feedback evolved over time. For Research Question 1, we investigated the students' perceived value of different feedback sources—buddies, simulated patients, video annotations, and tutorial discussions—across the four sessions where each student acted as the doctor. This analysis was based on inductive analysis of semi-structured interviews conducted after these sessions. Research Question 2 focused on understanding the reasons behind the changes in students' perceived value of these four distinct feedback (buddies, simulated patients, video annotations, and tutorial discussions) during the SPCs. To assess the reason behind these shifts, we combined data from the observation notes and semi-structured interviews, which captured students' evolving perceptions across the four SPCs. Participants The course consisted of 10 students from the international track of medicine program (male = 1, female = 9; Mean age = 21) who began their learning at the start of the course. The students were from different European countries and the course was taught in English. All students participated voluntarily and provided signed consent. Ethical approval for the study was granted by the Faculty of Health, Medicine, and Life Sciences Ethics Committee of XXX University (Approval Number: FHML-REC/2021/129). Instruments The first research question was answered through ranking in closed questions in semi-structured interviews. Four how and why questions were designed to answer the first research question: How would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the first SPC? Can you explain why you give this rank? How would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the second SPC? Can you explain why you give this rank? How would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the third SPC? Can you explain why you give this rank? How would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the last SPC? Can you explain why you give this rank? To address Research Question 2, HY maintained observation notes to document students' performance and reactions during the interactive tutorial discussions to support the interview findings. To minimize potential bias, HY adhered to a pre-defined observation protocol and maintained a neutral tone while recording student behaviors and feedback interactions (Appendix A ). HY quietly sat in the corner of the discussion room, maintaining no contact with the students or the tutor throughout the course. The observation notes were maintained at six different time points throughout the course. The first four time points corresponded to the observation notes entries that recorded the tutorial discussions following each of the four SPC sessions. The last two entries documented the tutor's review of each student's performance across the four SPC sessions and provided general instructions for improvement. After each tutorial discussion, the tutor and HY reviewed the observation notes to ensure the accuracy of its content. The interview guide consisted of open-ended questions designed to elicit detailed insights regarding the students’ experience in medical communication learning as well as appreciations of feedback across different SPCs of the course. Each interview was conducted in a comfortable setting to promote open dialogue, audio-recorded, and transcribed verbatim for analysis. Interviews were completed with all 10 students participating in the study. Each interview lasted between 50 and 60 minutes and concluded when the interviewer determined that all questions had been adequately addressed, and no further new information was being revealed. Data analysis We conducted an inductive thematic analysis on all 10 transcripts following Braun and Clarke ( 26 ) six-phase methodology. Three researchers (H.Y., Z.L., and M.A.) first immersed themselves in the data through repeated independent transcript reviews (Phase 1: Familiarization), identifying preliminary patterns. Through an iterative process of open coding, they systematically generated initial codes for data segments relevant to the research questions (Phase 2: Generating Initial Codes). The team then collaboratively organized these codes into potential themes through consensus-based discussions (Phase 3: Searching for Themes), ensuring thematic coherence with study objectives. We rigorously reviewed all candidate themes against the complete dataset (Phase 4: Reviewing Themes), verifying their representativeness through iterative discussions that resolved interpretive discrepancies. Emerging themes were refined and formally defined (Phase 5: Defining/Naming Themes) through triangulation with observational notes from tutorial discussions, enhancing analytical rigor through cross-validation. Throughout this process, the team engaged in reflexive discussions to mitigate researcher bias, maintaining methodological objectivity. The final analysis (Phase 6: Producing the Report) yielded four distinct themes that comprehensively captured participants' evolving perceptions of feedback value, supported by direct quotations and observational evidence. These themes align with Research Question 2, which focused on understanding the reasons behind the changes in students' perceived value of feedback from different sources—buddies, simulated patients, video annotations, and tutorial discussions—during the SPCs. Result Rank of students’ perceptional value of feedback by four SPCs. Research Question 1 focused on understanding how students' perceptional value of feedback evolved over the four timepoints. Table 1 displays the rank of students’ perceptional value of feedback regarding the four sources—buddies, simulated patients, video annotations, and tutorial discussions—as they progress through the SPC. Table 1 Rank of students’ perceptional value of feedback by four SPCs. SPC 1 SPC 2 SPC 3 SPC 4 Rank 1 Simulated Patient Feedback Student-Buddy Feedback Student-Buddy Feedback Tutorial Discussions Rank 2 Tutorial Discussions Simulated Patient feedback Tutorial Discussions Annotation Feedback Rank 3 Student-Buddy Feedback Tutorial Discussions Annotation Feedback Student-Buddy Feedback Rank 4 Annotation Feedback Annotation Feedback Simulated Patient feedback Simulated Patient feedback According to Table 1 , after the first SPC, students ranked simulated patient feedback as the most valued, followed by tutorial discussions, student-buddy feedback, and annotation feedback. At the second SPC, students placed the highest value on feedback from peers in a buddy system, followed by feedback from simulated patients, discussions in tutorials, and written annotations. Over time, during SPC 3, students rated student-buddy feedback as the most valued, followed by tutorial discussions, annotation feedback, and simulated patient feedback. At SPC 4, students rated tutorial discussions to be the most valued feedback, followed by annotation feedback, student-buddy feedback, and simulated patient feedback. Evolution of Students' Perceptions of Feedback across four SPCs To address Research Question 2, we deepened our investigation into the how and why of student’s responses shown in Table 1 . Additionally, we cross-checked observation notes at each time point with each student’s interview reports of their four SPC performances. This methodical comparison between the observation notes and the interview responses provided a thorough analysis of the participants' evolving perspectives on feedback throughout the SPC process. We applied inductive thematic analysis to our data, incorporating a cognitive load theory perspective to explore students' mental processes and the role of feedback in shaping their learning strategies. Our study examined how students’ experiences and perceptions of value of feedback change as students’ progress during the four SPCs. Our study focused on understanding how cognitive load impacts students' learning, how feedback mechanisms can correct misconceptions, direct attention to crucial learning tasks, and foster the development of mental schemas that enhance comprehension and retention. Through this lens, we examined students' evolving perceptions of feedback from different sources during simulated patient consultations (SPCs). Through this analysis, we identified four key themes: navigating through stress, adapting to the challenge, enhancing the learning efficiency, and listening to the full story. Theme 1 - Navigating Stress: The Dynamics of Feedback Utilization and Learning Choices Students reported feeling stressed or nervous during the simulated patient consultations at the initial encounters with the SPs in their consultations. One student described the stress as intense — “almost panicking” — and said it even drove them to “ stop the SPC ” (S1) "At the start of the SPC, I was extremely stressed—almost panicking—and couldn’t think of any solutions. I even considered stopping. I struggled to explain or resolve the issue during the process, and later found that my peers also couldn’t identify alternatives. I was worried the consultation was going poorly. However, I still managed to address the simulated patient’s issue and gather all the necessary information. In the end, it was a successful consultation, even if the communication wasn’t as smooth as I’d hoped." (S1). As they gained more experience in later SPC sessions, students described their communication as becoming more natural and confident. This shift appeared to go beyond mere familiarity; repeated exposure seemed to support the internalization of professional roles and reduce the cognitive burden of managing stress. For example, one student said: “I wasn’t panicking and didn’t need to pause the timer to collect my thoughts. After going through several SPC rounds, I now feel more like a doctor than a student learning to become one.” (S9) Students appreciated and relied on teacher guidance to manage the stress they experienced during SPCs. For example, one student shared that the teacher’s support helped them feel more at ease and shift their focus away from trying to deliver a perfect consultation, toward using the experience as a learning opportunity through feedback. “After speaking with the teacher, my stress eased a bit. She reminded me that I don’t need to be a perfect doctor right away, and there’s no shame in making mistakes. What matters is learning from feedback and avoiding similar issues in the future. For example, I now feel more confident about doing open-door physical exams without getting too nervous”. (S5) The students reported that peer comparison can lead to stress in some circumstances. For example, when they compared their experiences and coping strategies with those of their more experienced peers, they initially felt stressed. They noted that this comparison brought stress, but the stress tended to go away quickly as they recognized that they shared a similar learning pace with other peers. For instance, one student stated, At first, I felt quite stressed because I kept comparing myself to peers with clinical experience. They seemed so confident and in control, while I was still trying to manage my stress and stick to the structure. It made me feel like I was falling behind. But during the second SPC, I realized they also make mistakes. That helped me see I’m learning and progressing just like everyone else—and the stress started to fade. " (S4) Beyond peer comparison, some students also experienced stress from how they perceived the role of the simulated patient. Student 8, who had never interacted with an SP before, described the encounter as feeling “supervised,” and explained that they valued SP feedback much like they would feedback from a tutor. “ There’s nothing wrong with asking the SP for feedback—after all, they represent real patients and have experience with many students. I see the SP as a kind of tutor who can help me identify mistakes during the simulation. The feedback I received was helpful and felt accurate, even though it became a bit inconsistent later on .” (S8) The students reported that stress sometimes led them to overlook minor details during the SPC, such as missing a patient cue or forgetting to summarize. They described feeling discouraged when they realized these mistakes, which increased their stress and made it harder to stay focused during the consultation. However, some students noted that discussing their performance with peers helped them identify what they had missed and understand how to improve. For example, they reported that peer feedback provided specific suggestions—such as using reminders or structuring their questions—which helped them feel more in control and better prepared in later sessions. For example, one student noted, "I was so focused on asking the right questions that I forgot to summarize the patient’s responses at the end. My peer later suggested using phrases like, “So just to check, you said…” as a reminder. That simple tip really helped in the next round by giving me a clear structure to follow when things felt chaotic." (S8). Theme 2 - Adapting to the Challenge: How Much to Prepare and What to Do Spontaneously The students reported that they encountered different difficulties or unexpected events in each SPC. Some tried to prepare in advance to reduce these challenges, but challenges also arose during the preparation itself. They described feedback as a “ shared resource ” (S7) that helped them work through these difficulties together. For example, one student explained, " For my SPC, I had just written down a few questions, and I didn’t really look at them much. I think it was very important for me to go in sort of unprepared, because that’s how it will be as a doctor when patients come to you. That’s what I was trying to practice—going in a bit less prepared and going with the flow of the conversation, rather than preparing so much that I couldn’t deviate when the conversation naturally took a different direction. I think it’s not always necessary to prepare in advance, because the feedback is, in a way, a shared resource that already helped me shape the talk. That’s also the kind of feedback I would give to my peers. " (S10) Another student mentioned, " Preparing notes doesn’t always help, since you can’t predict what the SP will say. The SPC isn’t a fixed recipe—it changes from case to case. Notes can feel reassuring, but it’s easy to rely on them too much, even when they’re not truly useful. One of my learning goals is to handle the consultation without depending on notes, because SPC is about simulating real-life scenarios, and it needs to feel authentic .” (S3) The students reported that they took notes during SPCs, using either laptops or paper. They emphasized that both note-taking and typing skills were important. Many students mentioned struggling with these skills, explaining that they often found it “ difficult to keep up with note-taking while taking the patient’s history ” (S7). For example, one student stated, “ Taking doctor notes to document your thoughts and what the patient is saying can disrupt the flow — especially when typing, which is harder than writing on paper. Still, you know you have to learn to type, listen, and respond all at once. It’s just difficult right now. Over time, I’ve learned to adapt to the unexpected during SPCs .” (S5) another student mentioned, “I don’t think it’s correct to tell the patient to slow down and wait for me to take notes. It is difficult to keep up with note-taking while taking the patient’s history. Some of the patient very nicely wait for me, but some patients start to repeat key words just to accommodate my writing speed, which feels awkward for me.” (S7) Theme 3 - Reflections to Automate Actions and Consultation Structure The students reported that as they participated in more SPC sessions, they became more familiar with the structure of medical consultations. They reflected that “ After internalizing the three consultation phases, communication skills improved more quickly ” (S1). For example, one student mentioned, " Now, at the third SPC, and having received so much feedback on how to structure my SPCs during the tutorial discussions, I would say that I am just beginning to internalize the structure of the consultation process." (S3) The students reported that over time, their focus shifted from detailed learning goals to concentrating more on the overall consultation structure. They explained that they wanted their consultations to feel “ natural while remaining structurally clear enough .” (S4). For example, one student noted, " It (the consultation structure) helped me in the sense that I knew what a consultation should look like, because, for example, for the first two SPCs. I was just extremely focused on everything I was saying, and absolutely everything I was doing. But in later SPCs, I just learned what things I don't need to focus on anymore (structured phases of a consultation), because I was doing it naturally, when I am the doctor in the SPC, the structure of how to conduct a consultation becomes clear enough that I no longer need to follow external guidance ."(S4) The students reported that time management was important for maintaining the consultation structure. They shared their thoughts on why time management can be challenging, “ how much time to give patients to share their concerns” (S10) . Another student also noted that, "Sometimes I talk just to fill the silence because I’m unsure what to ask. I end up asking random questions simply to avoid awkwardness with the SP." (S7) The students also reported that they learned to use their time wisely by asking “ a mental listed of questions ” (S5) rather than random ones. They explained that this helped make their communication more efficient. For example, one student said, "I mentally check my detailed list of history taking items and ask the patient. In earlier sessions, I asked too many random questions that didn’t follow a clear path—it took time to rule things out one by one. Random questions aren’t time-efficient, since you never know if the SP will give a long story or just say no. You really need to ask to the point questions and having a mental list, helps to pick the relevant ones." (S9) Theme 4 - Dealing with the Bottleneck: Emotions are Heavy and Silent The students reported that when reflecting on their SPC experiences, they often felt like novices. For example, one student mentioned, "I still feel like a novice in consultations—my own thoughts distract me, making me focus too much on the medical issue and miss subtle patient cues, like hesitation or emotion. I shared this in the tutorial, and others felt the same." (S8) Students discussed the skill of persuading patients about antibiotic use, especially when patients are swayed by family stories or past experiences. Many students shared their experiences; for example, one student said: "I had a patient who insisted on antibiotics because they mentioned that their family had successfully used them in the past for similar symptoms. They were convinced that antibiotics were the only solution. I had to explain that each case is different and that antibiotics are not always necessary. I emphasized the importance of not overusing antibiotics to avoid resistance and explained the potential risks. It was challenging, but I tried to be empathetic and provide clear, evidence-based information to help them understand."(S7) The students reported that patients’ strong emotions or demands sometimes left them momentarily quiet or at a loss for words. Although this was a rare experience, they recognized it as something they needed to learn to manage. Several students recalled moments when they became silent after feeling overwhelmed by a patient’s strong feelings or requests. For example, one student noted, " Patients often come in with strong beliefs about their symptoms, which can be misleading, and they give you emotional pressure to control the talk. This threw me off and made it hard to stay in control of the conversation. In one case, the SP just wanted a sick note, and later pointed out that I focused too much on medical details instead of seeing the bigger picture ."(S5) The students reported that empathy played a key role in their SPC performance, especially in helping them improve further. Several shared that they invested more emotional effort to improve their communication and described how they learned to express empathy appropriately. For example, one student mentioned, " Your attitude towards the SP is important; it can really affect how well the consultation goes. Being genuine is a big part of it, but empathy is more than just being real. You gotta listen, really listen, and show you care about what they’re going through. Sometimes, you just need to pause and think about what they said before you respond. That’s why it works with some patients and not with others. It’s not just about being a doctor; it’s about humanistic characteristics and helping the patient feel heard . (S6) The students reported that being natural in their communication—treating patients as people rather than just cases—was essential for improving and overcoming challenges. One student added, " I always try to be as much myself as possible, while of course following a certain structure for the consultation so in that sense, maybe it’s not completely free or natural dialogue, but this is the way I’ve found helpful in letting the patient share their complaints with me. You don’t always take them as client or a problem to solve. They are humans with emotions ." (S8) The observational data corroborated and enriched the themes identified through the thematic analysis of the interview transcripts, indicating strong convergence between self-reported experiences and observed behaviours. Across simulated patient consultations (SPCs), observer noted patterns of behavior that aligned closely with students’ expressed feedback preferences and learning strategies. In some cases, the observations also illuminated subtle, unspoken aspects of feedback use – such as non-verbal reassurance seeking, time management adaptations, and emotional self-regulation – that students did not explicitly articulate in interviews. Table 2 presents those four overarching themes, each accompanied by representative observation notes. Within each theme, subcodes illustrate specific behaviors, from reliance on tutor guidance in early consultations to increasingly autonomous structuring of patient interactions. Together, these data provide a multi-faceted view of how students navigate stress, adapt preparation strategies, internalize consultation frameworks, and manage the emotional demands of patient communication. Table 2 Themes and Representative Quotes Identified from Observation Notes. Themes and codes Quote from the observation notes Theme 1 - Navigating stress: The dynamics of feedback utilization and learning choices Reliance on Teacher Guidance “In the tutorial discussion, the student paused mid-sentence, looked at the tutor, and waited. The tutor said, ‘It’s okay to make mistakes.’ The student nodded and continued explaining their consultation choices.” (Obs 1, S1) Peer Comparison “During the group discussion, the student said they had tried to use the same opening question that another peer had used in the previous SPC because it seemed to work well.” (Obs 5, S5) Oversight of minor details “When reflecting on their SPC, the student admitted forgetting to close the door after the SP entered. Another student reminded them, and the group laughed.” (Obs 4, S4) Coherence in Consultations “In the discussion, the student described how their questions in the SPC followed one another more smoothly than before, crediting a tip from the previous tutorial.” (Obs 3, S10) Theme 2 - Adapting to the challenge: How much to prepare and what to do spontaneously. Bringing notes and scripts for confidence “The student held a handwritten list of questions during the discussion and explained it was the same one they had used in the SPC to help keep on track.” (Obs 2, S2) Note-taking during the SPC “In the group, the student said they had jotted down key words while the SP was speaking and that this approach came from a peer’s earlier suggestion.” (Obs 4, S8) Making summaries after each phase of the consultation “The student described summarizing the patient’s history in the SPC and said this was a technique they had learned from feedback in the previous tutorial.” (Obs 5, S7) Theme 3 - Reflections to automate actions and consultation structure Going quicker from novice to expert “The student told the group they had started the SPC hesitantly but became more confident as it progressed, which they linked to practising tips from earlier discussions.” (Obs 3, S3) Internalizing the consultation structure and the three phases “Without prompting, the student described moving through history-taking, diagnosis, and management in their SPC, noting this matched the structure discussed in tutorials.” (Obs 2, S9) Time management “In the discussion, the student said they kept an eye on the clock during the SPC so they could finish all sections on time, a suggestion they credited to a peer.” (Obs 6, S4) Relevant question asking “The student explained that in the SPC they set aside their checklist and asked follow-up questions based on the SP’s responses, as recommended in a previous tutorial.” (Obs 4, S5) Theme 4 - Dealing with the bottle neck: emotions are heavy and silent. Reacting correctly towards the patient “The student recounted that when the SP became frustrated, they softened their tone and rephrased questions, a technique they had practised during role-play in the tutorial.” (Obs 4, S4) Handing strong emotions “During the discussion, the student described pausing and taking a breath when delivering difficult news in the SPC, something they said was suggested by the tutor.” (Obs 3, S6) Empathizing appropriately “The student said they had leaned forward and responded to the SP’s personal story with, ‘That sounds very difficult for you,’ which they had tried after SP feedback from an earlier session.” (Obs 6, S5) Persuading the patient “The student told the group they used an analogy to explain why antibiotics were not needed, an idea they said came from their buddy during preparation.” (Obs 5, S1) Discussion This study explored how medical students perceived and engaged with different sources of feedback—buddies, simulated patients (SPs), video annotations, and tutorial discussions—across four simulated patient consultation (SPC) sessions, and how these perceptions changed over time. Drawing on cognitive load theory ( 13 – 15 ) and feedback sense-making ( 10 , 12 ), the results indicate that students’ feedback preferences shifted over the course of the four SPCs in ways that generally corresponded with changes in their familiarity with the task and developing communication skills. The four identified themes— Navigating Stress: the dynamics of feedback utilization and learning choices , Adapting to the Challenge : how much to prepare and what to do spontaneously, Bringing notes/scripts for confidence , Reflections to automate actions and consultation structure , and Dealing with the Bottleneck: emotions are heavy and silent —help explain these shifts and underscore the interdependent roles of feedback and cognitive management in learning complex communication skills. Research Question 1: Perceived Value of Feedback Sources Across SPCs The patterns reported in Table 1 show that after the first SPC, students valued simulated patient feedback most highly, followed by tutorial discussions, student-buddy feedback, and finally annotation feedback. This preference is consistent with Theme 1: Navigating Stress: the dynamics of feedback utilization and learning choices , where students described feeling anxious and uncertainty during their initial SPCs. Feedback from SPs was perceived as most authentic and directly relevant, offering specific, patient-centered suggestions that helped students link their performance with the expectations of real consultations. The immediacy and realism of SP feedback appeared to provide an accessible starting point for making sense of their performance ( 14 , 15 ). At the second SPC, the highest value shifted to student-buddy feedback, followed by SP feedback, tutorial discussions, and annotation feedback. Comments from students indicated that peer input felt relatable and encouraging, which may have helped reduce perceived pressure and normalized their learning challenges. This aligns with Theme 2: Adapting to the Challenge: how much to prepare and what to do spontaneously , where feedback functioned as a collaborative shared resource, helping students navigate the unpredictability of consultations and exchange practical improvement strategies. By the third SPC, student-buddy feedback remained the most valued, followed by tutorial discussions, annotation feedback, and SP feedback. At this stage, students expressed more comfort with peer critique and placed increasing emphasis on tutor guidance and discussions in the tutorial session to refine their performance, consistent with Theme 3: Reflections to automate actions and consultation structure . As they became more familiar with the consultation structure, students appeared better able to engage with multiple feedback sources, including annotation feedback, to support reflection and skill refinement ( 13 – 15 ). At the fourth SPC, tutorial discussions were rated highest, followed by annotation feedback, student-buddy feedback, and SP feedback. This shift suggests a greater reliance on structured, integrative feedback to reflect, while the reduced emphasis on SP feedback likely reflects increased confidence in meeting patient interaction expectations. Research Question 2: Reasons Behind Shifts in Feedback Perceptions The shifts in feedback preferences can be understood through the interplay of students’ developing familiarity with SPCs, evolving cognitive load management and capacity for feedback sense-making. Initially, high stress and lack of familiarity created a heavy cognitive load ( Theme 1 – Navigating stress: the dynamics of feedback utilization and learning choices ), limiting students’ ability to process more complex or less immediate feedback. This was especially evident in early simulated patient consultations (SPCs), where students described feeling “extremely stressed—almost panicking” (S1) and even considered stopping the consultation altogether. Such intense emotional responses made it difficult for students to focus on nuanced feedback or reflect deeply during the session. In these moments, feedback that was concrete, immediately relevant, and clearly linked to observable behaviors was easier to act upon than feedback that required delayed reflections. In this context, SP feedback provided direct, relevant pointers that helped clarify learning goals. For example, one student noted that they viewed the SP as “a kind of tutor” whose feedback was “helpful and felt accurate,” (S8) especially in identifying mistakes during the simulation. Because SP comments often mirrored the patients’ real-time reactions-such as noting when an explanation was unclear or when empathy was missing-students could immediately adjust their communication strategies in subsequent role-plays or even within the same SPC. This immediacy and relevance made SP feedback more accessible and actionable under stress, helping students to priorities essential communication steps and regain a sense of control over the consultation. In contrast, less interactive feedback—such as video annotations—was less frequently used or valued early on. Students reported that although these annotations contained useful insights, they were often received too late to be acted upon in the same SPC, making them harder to integrate under pressure. They were often too overwhelmed to engage with delayed or abstract forms of feedback. As one student shared, “I was so focused on asking the right questions that I forgot to summarize the patient’s responses,” (S8) and only realized the mistake after peer feedback provided a simple, structured tip. This example illustrates that peer feedback, when offered immediately after the consultation, was more likely to result in quick behavioral adjustments than delayed, and through non-interactive sources. This highlights how real-time, interactive feedback was more effective in helping students manage cognitive load and improve performance during early SPCs. As students became more comfortable ( Theme 2 – Adapting to the challenge: how much to prepare and what to do spontaneously ), they began to engage more actively with peer feedback, recognizing it as a source of reassurance and practical guidance. This collaborative interpretation of feedback appeared to help students manage uncertainty and focus on targeted improvements ( 10 , 19 , 20 ). One student described feedback as a “shared resource” (S10) that shaped their consultation approach and was also something they offered to peers. In these later discussions, peers were not just recipients of advice but co-constructors of strategies, helping one another adapt to both predictable and unexpected moments in the consultation. This framing highlights how feedback evolved from a one-way input into a mutual learning tool. In later SPCs, greater familiarity and partial automation of consultation routines allowed students to shift their focus from rigid preparation to adaptive communication. For instance, one student reflected, “I think it’s not always necessary to prepare in advance, because the feedback is, in a way, a shared resource that already helped me shape the talk” (S10). Another added, “The SPC isn’t a fixed recipe—it changes from case to case,” (S3) emphasizing the need for flexibility over scripted responses. Here, peer and tutor feedback together provided the scaffolding for students to experiment with spontaneous communication while maintaining overall structure, reflecting a shift in the perceived value of these sources toward fine-tuning rather than basic skill acquisition. Students also began to recognize and address practical challenges collaboratively, such as note-taking during consultations. One student explained, “Taking doctor notes… can disrupt the flow—especially when typing,” but noted that over time, they learned to “adapt to the unexpected during SPCs” (S5). Observations from tutorial discussions showed that these exchanges often included concrete peer-generated tips—such as alternative ways to capture information without breaking rapport—which students reported implementing in subsequent SPCs. These shared experiences and peer strategies helped students navigate the evolving demands of SPCs with greater confidence and authenticity ( 27 ). In later SPCs, greater familiarity and partial automation of consultation routines ( Theme 3 – Reflections to automate actions and consultation structure ) freed cognitive resources for engaging with more detailed and self-directed feedback. Students reported that internalizing the structure of medical consultations helped streamline their communication. As one student reflected, “After internalizing the three consultation phases, communication skills improved more quickly” (S1), while another noted, “I am just beginning to internalize the structure of the consultation process” thanks to repeated feedback during tutorial discussions (S3). In these cases, tutor feedback played a central role in reinforcing core structures, while peer discussion helped personalize and contextualize the application of these structures in varied cases. This growing familiarity allowed students to shift their focus from granular learning goals to maintaining a natural yet structured flow. One student explained, “In later SPCs, I just learned what things I don't need to focus on anymore… because I was doing it naturally” (S4). This sense of automation enabled students to engage more meaningfully with tutor and peer feedback, which became particularly valuable for refining finer points of communication. Video annotation feedback, which had been used less often earlier, now gained relevance as students had the cognitive space to revisit their performance and apply nuanced corrections. Time management also emerged as a key skill that developed alongside structural familiarity. Initially, students struggled with pacing, sometimes asking “random questions simply to avoid awkwardness” (S7). However, with experience, they began using mental checklists to guide their questioning more efficiently. As one student shared, “Having a mental list helps to pick the relevant ones… Random questions aren’t time-efficient” (S9). This improvement was often driven by targeted advice in tutorial discussions and, at times, by annotation feedback that drew attention to how students used their time during the consultation. This evolution in strategy reflects how annotation feedback and tutorial discussions supported purposeful self-review and helped students refine their consultation techniques. Theme 4 – Dealing with the bottleneck: emotions are heavy and silent highlights that emotionally demanding scenarios—such as handling resistance or strong emotions—still required support. Students frequently described feeling like novices, with one noting, “My own thoughts distract me, making me focus too much on the medical issue and miss subtle patient cues, like hesitation or emotion” (S8). These moments of uncertainty were often shared in tutorial discussions, which offered a safe space for sense-making and rebuilding confidence. In these moments, feedback from the tutor was often instrumental in reframing challenges and offering communication strategies, while peers provided empathy and shared coping tactics. Tutorials also helped students navigate emotionally charged consultations, such as persuading patients about antibiotic use. One student recounted, “I had to explain that each case is different and that antibiotics are not always necessary… I tried to be empathetic and provide clear, evidence-based information” (S7). In this case, SP feedback on patient perspective combined with tutor input on phrasing strengthened the student’s ability to respond effectively in real time ( 28 ). These experiences underscored the emotional as well as cognitive role of feedback, especially when students felt overwhelmed or momentarily at a loss for words. Students recognized that empathy was central to managing these challenges. As one student put it, “Empathy is more than just being real… You gotta listen, really listen, and show you care” (S6). Another emphasized the importance of treating patients as people, not just cases: “They are humans with emotions” (S8). Feedback from SPs was particularly valuable here, as it provided insight into whether empathy was actually perceived by the patient, giving students an external validation of their intentions. These reflections show how tutorial discussions supported the development of humanistic communication skills, helping students move beyond technical competence toward emotionally intelligent practice ( 28 ). Overall, the results suggest that feedback preference evolved systematically alongside students’ progression in SPCs, reflecting their changing cognitive and emotional needs rather than arbitrary variation. Implications The findings of this study carry important implications for medical education practice. First, the clear, stage-based shifts in students’ feedback preferences reinforce the need for feedback approaches that are both flexible and developmentally responsive. Educators should adapt feedback delivery over time, aligning it with learners’ evolving cognitive load management abilities and emotional readiness. Early-stage learners benefit from authentic, patient-centered feedback that helps them navigate uncertainty and clarify performance expectations, while more advanced learners require feedback that deepens reflection, supports self-regulation, and strengthens professional identity. Second, the increasing importance of peer feedback and tutorial discussions in later stages highlights the value of structured, collaborative learning opportunities. Incorporating purposeful peer-to-peer interaction alongside expert-guided reflection can enhance learners’ ability to interpret complex feedback and internalize advanced communication skills. Medical curricula should therefore scaffold feedback opportunities, moving intentionally from highly guided, externally focused input toward learner-driven, reflective, and peer-supported feedback ecosystems. Limitations This study provides valuable insights but has limitations. The small, single-institution sample may limit the generalizability of findings; multi-site studies with diverse student cohorts are needed to capture broader feedback experiences. Additionally, while this study focuses on SPC-related feedback, students’ communication skill growth may also have been influenced by concurrent curricular or clinical learning experiences not examined here. The cross-sectional design—capturing snapshots at each SPC—limits the ability to follow individual developmental feedback trajectories. Longitudinal research could more precisely track how feedback preferences and sense-making evolve within the same learners over time. Finally, this study did not examine how feedback mode or delivery style (e.g., dialogic vs. unidirectional) might influence interpretation and integration; future research should address these factors. Future Directions Building on these findings, future research should examine the long-term impact of varied feedback strategies on medical students’ professional development and communication skills, following learners into clinical training and practice. Studies extending beyond simulated settings into authentic patient care contexts would clarify how feedback habits transfer to real-world environments. Comparative research across different medical schools, specialties, and cultural contexts could inform more tailored feedback approaches. In addition, as technology becomes more embedded in medical education, investigating the role of digital modalities—such as enhanced video annotations, immersive simulations, and AI-supported feedback—could identify ways to optimize cognitive load while promoting deep reflection. Such work will support the creation of adaptive, evidence-based feedback systems that evolve alongside learners’ developmental stages and cognitive capacities. Conclusion This study demonstrates that medical students’ feedback preferences during simulated patient consultations change in predictable ways that mirror their growth in communication competence and cognitive load management. Initially, SP feedback provides emotional reassurance and concrete guidance, but as learners’ confidence and self-regulation increase, they shift toward valuing peer insights, structured tutorial dialogue, and eventually self-directed video annotation. These changes reflect a move from external validation toward autonomous, cognitively rich feedback engagement. Designing feedback practices that anticipate and support these developmental shifts can better equip medical students to manage cognitive demands, make sense of complex input, and continually refine communication skills—ultimately improving patient care. Abbreviations SPC simulated patient consultation Declarations Authors' contributions H.Y., M.A. and J.v.M. conceived the presented idea. M.A., S.E.K and J.v.M. verified the analytical methods. H.Y. and Z.L. analyzed the data. H.Y. drafted the manuscript under the supervision of M.A. and S.E.K. Acknowledgements We regretfully note that Professor Jeroen J. G. van Merriënboer passed away during the preparation of this manuscript. His contributions to the conceptualization and early development of this work were invaluable. We are deeply grateful for his guidance and insights, which have left a lasting impact on our research. We appreciate SkillsLab Coordinator Consult Ingrid Caubergh for taking the time to provide additional feedback on the manuscript. We appreciate the connections that SkillsLab Sandy Nelissen - Graven has been given to make sure the data authorization. Authors' information Hao Yu https://orcid.org/0000-0002-0821-8018 Zhien Li https://orcid.org/0009-0007-2223-8940 S. Eleonore Köhler https://orcid.org/0000-0003-1977-9977 Maryam Asoodar https://orcid.org/0000-0001-6044-6790 Ethics approval and consent to participate All students and patients volunteered to participate in the study and signed consent forms. Written informed consents were obtained from all students and simulated patients. All methods were carried out in accordance with relevant guidelines and regulations. The study was approved by the Ethics Review Committee of the Faculty of Health, Medicine and Life Sciences, Maastricht University (FHML-REC/2021/104). Consent for publication Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available according to the participation consents. However, they are available from the corresponding author on reasonable request. Competing interests All authors declare that they have no established conflicting financial interests or personal relationships that may have influenced the research presented in this paper. Funding This project was funded by SURF.nl (project number: OO20-17) and the School of Health Professions Education (SHE) at Maastricht University. H. Y. was supported by a scholarship granted by the China Scholarship Council (CSC, 202008440338) References Kurtz S, Draper J, Silverman J. Teaching and learning communication skills in medicine: CRC press; 2017. Mole TB, Begum H, Cooper-Moss N, Wheelhouse R, MacKeith P, Sanders T, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7426383","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":535153264,"identity":"0250ece2-4f25-4d43-a9e9-f22d552935f4","order_by":0,"name":"Hao Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIie3Ov0rEMBzA8YRA6hDPtUW0PkJKQe1w+iqWg3PRyUUQzpRCJrvr1FeoS9QtJdAuiqvjiS9wjoUOpqWcS6OrYL7Dj/zhEwKAzfYHo91YDRsJmZ6oX7vdgNJA4G23wj2ha9IbE0FkIKAnQ0ZyAMj+9vTsyPfz7F02j2384JDg47I9XFC5KcdIxDQ5F7OgqBxaZs80fkpJGLxw16VycjL6MdkTBAuMgYKcxoXCcy9hHSHUSCJxfZzzb3LasPYXAoWKWbUmqIIM/0AUvogyUc+Kag7KjIehJspLuOvdKQOp0/u3RlxN87RCq4bv7hSvZfLJ2sXWpL4JliMEoA06dqzbU4YL4Iy+pPOZidhsNts/6wsv/WdjzX52GAAAAABJRU5ErkJggg==","orcid":"","institution":"School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine and Life sciences, Maastricht University","correspondingAuthor":true,"prefix":"","firstName":"Hao","middleName":"","lastName":"Yu","suffix":""},{"id":535153265,"identity":"67564507-0de7-44c6-8a38-32b34c723753","order_by":1,"name":"Zhien Li","email":"","orcid":"","institution":"School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine and Life sciences, Maastricht University","correspondingAuthor":false,"prefix":"","firstName":"Zhien","middleName":"","lastName":"Li","suffix":""},{"id":535153266,"identity":"c8c621d1-5b79-4dd0-890e-596aebe25305","order_by":2,"name":"S. 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07:48:55","extension":"xml","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":130800,"visible":true,"origin":"","legend":"","description":"","filename":"aff9f6eb6077482eb7e49c8c9dce14a71structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7426383/v1/a8b33a36dc675d3bae20c827.xml"},{"id":94625519,"identity":"d311f4e2-8a2b-41a1-8ed6-e5b3d1f52c89","added_by":"auto","created_at":"2025-10-29 04:44:53","extension":"html","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":143898,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7426383/v1/0f0ce4dc790c9c994a84544a.html"},{"id":94639977,"identity":"73edd376-02b0-41b2-9f7e-11ac48298575","added_by":"auto","created_at":"2025-10-29 07:47:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":812612,"visible":true,"origin":"","legend":"\u003cp\u003eExample of ongoing simulated patient consultation.\u003c/p\u003e","description":"","filename":"Figure1.Exampleofongoingsimulatedpatientconsultation..png","url":"https://assets-eu.researchsquare.com/files/rs-7426383/v1/f88fd8e687006f001bbfe81a.png"},{"id":94625496,"identity":"aeed68bc-054f-4d99-b112-9ea46157c394","added_by":"auto","created_at":"2025-10-29 04:44:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":129784,"visible":true,"origin":"","legend":"\u003cp\u003eThematic framework of students’ perceptions of value of feedback evolves across SPCs.\u003c/p\u003e","description":"","filename":"Figure2.ThematicframeworkofstudentsperceptionsofvalueoffeedbackevolvesacrossSPCs..png","url":"https://assets-eu.researchsquare.com/files/rs-7426383/v1/ba1fc3015abdc4ae8e7b9d55.png"},{"id":94672053,"identity":"b0c8501d-5988-44f6-93af-46d4f33f5954","added_by":"auto","created_at":"2025-10-29 13:37:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2086764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7426383/v1/ad263968-11f2-43ae-b556-358681311eb2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Value to Valued: International Medical Students' Changing Views on Feedback Perception and Application in Communication Learning","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEffective communication is a cornerstone of quality healthcare, and its development during medical education is critical (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Feedback plays an essential role in this development by providing medical students with the necessary insights to refine their communication skills (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Given the importance of feedback, various methods have been explored to enhance its effectiveness in medical education. One such method is the use of Simulated Patients (SPs), which has been extensively studied and recognized as a valuable method for enhancing communication skills (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Simulated patient consultations (SPCs), a teaching method in which students interact with trained actors simulating real patients, provide a controlled yet realistic environment for students to practice and refine their medical communication skills (\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These studies highlight the importance of feedback within the context of SPCs in improving medical students' communication abilities and the process of making sense of feedback (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFeedback is crucial for medical students' skill development and professional growth(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, as students gain clinical experience, their perceived value of feedback nuances can evolve over time. This reflects shifting needs in learning, improved feedback interpretation, and a deeper understanding of feedback\u0026rsquo;s role in professional growth (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite the recognized importance of feedback in medical education, there is a significant gap in research regarding the evolution of students\u0026rsquo; perceptions of its value throughout their medical communication training. Understanding how learners perceive, and shifting their attention to different sources of feedback can greatly inform the design of more effective feedback strategies, ultimately enhancing the educational experience.\u003c/p\u003e\u003cp\u003eCognitive load theory offers a valuable framework for understanding how students process information and learn most effectively (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It emphasizes that the human cognitive system has limited capacity for processing new information, and instructional design should aim to optimize this capacity by managing cognitive load. This involves managing the natural difficulty of the material (intrinsic load), avoiding unnecessary complications (extraneous load), and supporting the development of lasting knowledge and skills (germane load) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Effective feedback can reduce the intrinsic learning loads in tasks (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), helping students identify and correct misconceptions (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Peer feedback, for instance, has been shown to lower extraneous cognitive load by providing relatable, actionable insights from learners at similar developmental stages (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe cognitive load theory also helps direct attention to the most crucial aspects of learning tasks, optimizing cognitive resources (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Drawing from the theory, research finds that clarifying the accuracy of students' understanding enhances their sense-making process of feedback, thereby streamlining cognitive processing and enhancing overall learning efficiency (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In alignment with these principles, simulated patient consultations provide a safe, authentic environment that enhances feedback quality, reduces cognitive load, and improves learning outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). For example, structured peer feedback during SPCs can help students prioritize actionable improvements, whereas simulated patient feedback often highlights experiential nuances (e.g., nonverbal communication) that peers might overlook (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). By applying cognitive load theory to the design of SPCs, students\u0026rsquo; strategy in engaging in independent problem solving, for example makings sense of feedback, and using feedback information becomes more comprehensive and cognitively manageable, thus supporting students in their journey to become proficient medical communicators.\u003c/p\u003e\u003cp\u003eWhile feedback is known to be essential for student learning, less is understood about how students perceive the value of feedback at different stages of learning. This study aims to explore how students perceive the value of feedback and how this perception evolves as they progress through SPCs and gain more experience in interpreting and applying feedback to improve the quality of their medical communication consultations.\u003c/p\u003e\u003cp\u003eResearch Questions:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow does the perceived value of feedback (from buddies, simulated patients, video annotations, and tutorial discussions) evolve as students\u0026rsquo; progress in their SPCs?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow does the students\u0026rsquo; perceptions of their learning process in Simulated Patient Consultations evolve as students' perceptions of the value of feedback from various sources (buddies, simulated patients, video annotations, and tutorial discussions) change over time?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch Team and Reflexivity:\u003c/h2\u003e\u003cp\u003eThe research team was a collaborative ensemble, featuring three medical education experts—J.v.M., S.E.K., and M.A.—each with a substantial background of over eight years in their respective areas of expertise. Together, they pooled extensive knowledge in medical education and instructional design research. Strengthening this core team were two PhD candidates, H.Y. and Z.L., who contributed three years of practical experience in medical education, enriching the study with their distinct viewpoints. H.Y., and M.A., adept in qualitative research methodologies, provided valuable insights particularly relevant to research and instructional design in simulated patient consultations. Z.L. and M.A. lent their expertise in thematic analysis and brought firsthand experience with educational interventions in healthcare settings. Additionally, M.A., J.v.M., and S.E.K. enriched the study by offering theoretical perspectives and critical insights, contributing to the research's comprehensive scope.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSetting of SPC\u003c/h3\u003e\n\u003cp\u003eIn our setting, we applied Cognitive Load Theory (CLT) to guide the design of high-fidelity learning environments that optimize medical students' learning experiences during Simulated Patient Consultations (SPCs). The SPC utilized a three-phase model to structure consultations. This model provides a comprehensive and transparent framework for both complaint-centered and follow-up consultations, helping medical students integrate patient-informed and medically informed pathways(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Phase one, focuses on clarification of the reasons for the encounter. Phase two, involves extended history taking and physical examination. Phase three, centers on explanation, dialogue, planning, and closing the consultation.\u003c/p\u003e\u003cp\u003eStudents prepared for their SPCs in a skills lab equipped with consultation desks, examination beds, and sanitary systems. Additionally, to a medical consultation setting, video recording equipment was installed in the corner of the consultation room which aimed to record students’ SPC and to upload it to the eLearning platform. Each SPC session involved three participants: one student-doctor, one student buddy (observer), and one simulated patient. The student buddy, a peer learner from the same course, acted as an observer to systematically assess the student-doctor’s performance during the SPC, providing first-person feedback that enhanced learning and skill development (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eDesign of SPCs\u003c/h3\u003e\n\u003cp\u003eSPCs were designed to manage intrinsic load by maintaining consistent complexity levels, focusing on one medical condition per session, and providing feedback and guidance through an eLearning platform and tutorial discussions. To minimize extraneous load, the consultation room was equipped with necessary tools, video recording equipment was used to capture sessions, and roles were clearly defined. Germane load was enhanced by incorporating multiple feedback sources, including student-buddy, simulated patient, and video annotation feedback, which supported schema development and long-term learning. Feedback included tips for improvement and points of pride, and students were encouraged to reflect independently before tutorial discussions to enhance learning outcomes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBefore the SPC began, the student-doctors prepared themselves in the consultation room, dropping bags, engaging in small talk and relaxing, and familiarizing themselves with their learning objectives. At the beginning of each SPC, the student-doctor and student buddy conducted a brief preparation session. The student-doctor outlined their learning goals and the focus areas for the consultation, while the student buddy initiated the recording system. This self-directed briefing ensured both participants were aligned and prepared for the session. Meanwhile, the simulated patient waited outside the consultation room, ready to be called in. Once the student-doctor was ready, they began the SPC by inviting the patient into the consultation room.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates an ongoing SPC, where one student took on the role of the doctor while their student buddy observed from a corner of the room. The student buddy closely monitored the student-doctor’s performance, tracking whether the learning objectives were met and noting areas for improvement. This observation allowed for a detailed examination of each stage of the consultation. The consultation was conducted with a trained simulated patient, who presented a complaint similar to that of a real patient.\u003c/p\u003e\u003cp\u003eUpon the consultation's conclusion, the first form of feedback exchanged was student-buddy feedback. The student buddy provided observations and informal feedback regarding communication. Throughout the course, students alternated between the roles of student-doctor and student buddy to ensure each participant experienced both perspectives. Following the student-buddy feedback, simulated patient feedback was provided. Simulated patient feedback was typically unstructured, with the basis of the feedback focusing on the questions the students asked the simulated patient. For instance, it included feedback on the clarity of sentences and the engagement of both verbal and non-verbal communication.\u003c/p\u003e\n\u003ch3\u003ePost-SPC Reflection and Video Annotation Feedback provided by the tutor and the peers\u003c/h3\u003e\n\u003cp\u003eAfter the SPC, the video recording of the consultation was uploaded to the University Learning Space, an online learning platform. The students and tutor had access to these recorded consultations and gave annotated feedback at specific points in the video. The timing of the feedback was not predetermined; instead, students and the tutor provided feedback a few days before the group discussion session. This allowed students ample time to familiarize themselves with and reflect on the annotations before the course. The video annotation feedback was designed to be balanced, incorporating both positive and critical elements. Students and the tutor gave positive feedback to highlight strengths, such as effectively demonstrating empathy or successfully delivering complex medical information. On the other hand, they provided constructive feedback that offered actionable suggestions for improvement, such as refining communication strategies or offering clearer medical explanations. Students were expected to review and reflect on the feedback they received through the annotations independently before the tutorial discussion sessions. This independent reflection was intended to help them identify areas for improvement and prepare for the group discussion. Unresolved or unclear feedback points are brought to the tutorial discussion sessions for further clarification.\u003c/p\u003e\n\u003ch3\u003eFollow-up Tutorial Discussions\u003c/h3\u003e\n\u003cp\u003eRoughly, a week after the SPC, all students gathered for a Tutorial Discussion with the whole class of 10 students and their tutor. During this session, individual SPC performances were reviewed, and feedback from the video annotations, student-buddy feedback, and simulated patient feedback were discussed in depth. With the tutor’s guidance, each student sets specific learning goals for the future to ensure they focus on areas for improvement. These face-to-face interactions provided the opportunity for the students to ask questions, seek clarification, and engage in group reflections on their learning goals and progress.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eResearch design\u003c/h2\u003e\u003cp\u003eIn this study, we employed a qualitative approach to examine the development of students' medical communication skills and how their perceptions of feedback evolved over time. For Research Question 1, we investigated the students' perceived value of different feedback sources—buddies, simulated patients, video annotations, and tutorial discussions—across the four sessions where each student acted as the doctor. This analysis was based on inductive analysis of semi-structured interviews conducted after these sessions. Research Question 2 focused on understanding the reasons behind the changes in students' perceived value of these four distinct feedback (buddies, simulated patients, video annotations, and tutorial discussions) during the SPCs. To assess the reason behind these shifts, we combined data from the observation notes and semi-structured interviews, which captured students' evolving perceptions across the four SPCs.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe course consisted of 10 students from the international track of medicine program (male = 1, female = 9; Mean age = 21) who began their learning at the start of the course. The students were from different European countries and the course was taught in English. All students participated voluntarily and provided signed consent. Ethical approval for the study was granted by the Faculty of Health, Medicine, and Life Sciences Ethics Committee of XXX University (Approval Number: FHML-REC/2021/129).\u003c/p\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003eThe first research question was answered through ranking in closed questions in semi-structured interviews. Four how and why questions were designed to answer the first research question:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003efirst\u003c/span\u003e SPC? Can you explain why you give this rank?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003esecond\u003c/span\u003e SPC? Can you explain why you give this rank?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ethird\u003c/span\u003e SPC? Can you explain why you give this rank?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow would you rank the four different feedback sources in terms of their values in helping you learn medical communication during the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003elast\u003c/span\u003e SPC? Can you explain why you give this rank?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTo address Research Question 2, HY maintained observation notes to document students' performance and reactions during the interactive tutorial discussions to support the interview findings. To minimize potential bias, HY adhered to a pre-defined observation protocol and maintained a neutral tone while recording student behaviors and feedback interactions (Appendix \u003cspan refid=\"Sec24\" class=\"InternalRef\"\u003eA\u003c/span\u003e). HY quietly sat in the corner of the discussion room, maintaining no contact with the students or the tutor throughout the course. The observation notes were maintained at six different time points throughout the course. The first four time points corresponded to the observation notes entries that recorded the tutorial discussions following each of the four SPC sessions. The last two entries documented the tutor's review of each student's performance across the four SPC sessions and provided general instructions for improvement. After each tutorial discussion, the tutor and HY reviewed the observation notes to ensure the accuracy of its content.\u003c/p\u003e\u003cp\u003eThe interview guide consisted of open-ended questions designed to elicit detailed insights regarding the students’ experience in medical communication learning as well as appreciations of feedback across different SPCs of the course. Each interview was conducted in a comfortable setting to promote open dialogue, audio-recorded, and transcribed verbatim for analysis. Interviews were completed with all 10 students participating in the study. Each interview lasted between 50 and 60 minutes and concluded when the interviewer determined that all questions had been adequately addressed, and no further new information was being revealed.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eWe conducted an inductive thematic analysis on all 10 transcripts following Braun and Clarke (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) six-phase methodology. Three researchers (H.Y., Z.L., and M.A.) first immersed themselves in the data through repeated independent transcript reviews (Phase 1: Familiarization), identifying preliminary patterns. Through an iterative process of open coding, they systematically generated initial codes for data segments relevant to the research questions (Phase 2: Generating Initial Codes).\u003c/p\u003e\u003cp\u003eThe team then collaboratively organized these codes into potential themes through consensus-based discussions (Phase 3: Searching for Themes), ensuring thematic coherence with study objectives. We rigorously reviewed all candidate themes against the complete dataset (Phase 4: Reviewing Themes), verifying their representativeness through iterative discussions that resolved interpretive discrepancies. Emerging themes were refined and formally defined (Phase 5: Defining/Naming Themes) through triangulation with observational notes from tutorial discussions, enhancing analytical rigor through cross-validation.\u003c/p\u003e\u003cp\u003eThroughout this process, the team engaged in reflexive discussions to mitigate researcher bias, maintaining methodological objectivity. The final analysis (Phase 6: Producing the Report) yielded four distinct themes that comprehensively captured participants' evolving perceptions of feedback value, supported by direct quotations and observational evidence. These themes align with Research Question 2, which focused on understanding the reasons behind the changes in students' perceived value of feedback from different sources—buddies, simulated patients, video annotations, and tutorial discussions—during the SPCs.\u003c/p\u003e\u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cb\u003eRank of students’ perceptional value of feedback by four SPCs.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eResearch Question 1 focused on understanding how students' perceptional value of feedback evolved over the four timepoints. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the rank of students’ perceptional value of feedback regarding the four sources—buddies, simulated patients, video annotations, and tutorial discussions—as they progress through the SPC.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRank of students’ perceptional value of feedback by four SPCs.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSPC 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSPC 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSPC 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSPC 4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRank 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSimulated Patient Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudent-Buddy Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStudent-Buddy Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTutorial Discussions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRank 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTutorial Discussions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSimulated Patient feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTutorial Discussions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAnnotation Feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRank 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent-Buddy Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTutorial Discussions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAnnotation Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStudent-Buddy Feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRank 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnnotation Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnnotation Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSimulated Patient feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSimulated Patient feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, after the first SPC, students ranked simulated patient feedback as the most valued, followed by tutorial discussions, student-buddy feedback, and annotation feedback. At the second SPC, students placed the highest value on feedback from peers in a buddy system, followed by feedback from simulated patients, discussions in tutorials, and written annotations. Over time, during SPC 3, students rated student-buddy feedback as the most valued, followed by tutorial discussions, annotation feedback, and simulated patient feedback. At SPC 4, students rated tutorial discussions to be the most valued feedback, followed by annotation feedback, student-buddy feedback, and simulated patient feedback.\u003c/p\u003e\u003ch2\u003eEvolution of Students' Perceptions of Feedback across four SPCs\u003c/h2\u003e\u003cp\u003eTo address Research Question 2, we deepened our investigation into the how and why of student’s responses shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Additionally, we cross-checked observation notes at each time point with each student’s interview reports of their four SPC performances. This methodical comparison between the observation notes and the interview responses provided a thorough analysis of the participants' evolving perspectives on feedback throughout the SPC process.\u003c/p\u003e\u003cp\u003eWe applied inductive thematic analysis to our data, incorporating a cognitive load theory perspective to explore students' mental processes and the role of feedback in shaping their learning strategies. Our study examined how students’ experiences and perceptions of value of feedback change as students’ progress during the four SPCs. Our study focused on understanding how cognitive load impacts students' learning, how feedback mechanisms can correct misconceptions, direct attention to crucial learning tasks, and foster the development of mental schemas that enhance comprehension and retention. Through this lens, we examined students' evolving perceptions of feedback from different sources during simulated patient consultations (SPCs). Through this analysis, we identified four key themes: navigating through stress, adapting to the challenge, enhancing the learning efficiency, and listening to the full story.\u003c/p\u003e\u003ch2\u003eTheme 1 - Navigating Stress: The Dynamics of Feedback Utilization and Learning Choices\u003c/h2\u003e\u003cp\u003eStudents reported feeling stressed or nervous during the simulated patient consultations at the initial encounters with the SPs in their consultations. One student described the stress as intense — “almost panicking” — and said it even drove them to “\u003cem\u003estop the SPC\u003c/em\u003e” (S1)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"At the start of the SPC, I was extremely stressed—almost panicking—and couldn’t think of any solutions. I even considered stopping. I struggled to explain or resolve the issue during the process, and later found that my peers also couldn’t identify alternatives. I was worried the consultation was going poorly. However, I still managed to address the simulated patient’s issue and gather all the necessary information. In the end, it was a successful consultation, even if the communication wasn’t as smooth as I’d hoped.\" (S1).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAs they gained more experience in later SPC sessions, students described their communication as becoming more natural and confident. This shift appeared to go beyond mere familiarity; repeated exposure seemed to support the internalization of professional roles and reduce the cognitive burden of managing stress. For example, one student said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I wasn’t panicking and didn’t need to pause the timer to collect my thoughts. After going through several SPC rounds, I now feel more like a doctor than a student learning to become one.” (S9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eStudents appreciated and relied on teacher guidance to manage the stress they experienced during SPCs. For example, one student shared that the teacher’s support helped them feel more at ease and shift their focus away from trying to deliver a perfect consultation, toward using the experience as a learning opportunity through feedback.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“After speaking with the teacher, my stress eased a bit. She reminded me that I don’t need to be a perfect doctor right away, and there’s no shame in making mistakes. What matters is learning from feedback and avoiding similar issues in the future. For example, I now feel more confident about doing open-door physical exams without getting too nervous”. (S5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe students reported that peer comparison can lead to stress in some circumstances. For example, when they compared their experiences and coping strategies with those of their more experienced peers, they initially felt stressed. They noted that this comparison brought stress, but the stress tended to go away quickly as they recognized that they shared a similar learning pace with other peers. For instance, one student stated,\u003c/p\u003e\u003cp\u003e\u003cem\u003eAt first, I felt quite stressed because I kept comparing myself to peers with clinical experience. They seemed so confident and in control, while I was still trying to manage my stress and stick to the structure. It made me feel like I was falling behind. But during the second SPC, I realized they also make mistakes. That helped me see I’m learning and progressing just like everyone else—and the stress started to fade. \" (S4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBeyond peer comparison, some students also experienced stress from how they perceived the role of the simulated patient. Student 8, who had never interacted with an SP before, described the encounter as feeling “supervised,” and explained that they valued SP feedback much like they would feedback from a tutor.\u003c/p\u003e\u003cp\u003e“\u003cem\u003eThere’s nothing wrong with asking the SP for feedback—after all, they represent real patients and have experience with many students. I see the SP as a kind of tutor who can help me identify mistakes during the simulation. The feedback I received was helpful and felt accurate, even though it became a bit inconsistent later on\u003c/em\u003e.” (S8)\u003c/p\u003e\u003cp\u003eThe students reported that stress sometimes led them to overlook minor details during the SPC, such as missing a patient cue or forgetting to summarize. They described feeling discouraged when they realized these mistakes, which increased their stress and made it harder to stay focused during the consultation. However, some students noted that discussing their performance with peers helped them identify what they had missed and understand how to improve. For example, they reported that peer feedback provided specific suggestions—such as using reminders or structuring their questions—which helped them feel more in control and better prepared in later sessions. For example, one student noted,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I was so focused on asking the right questions that I forgot to summarize the patient’s responses at the end. My peer later suggested using phrases like, “So just to check, you said…” as a reminder. That simple tip really helped in the next round by giving me a clear structure to follow when things felt chaotic.\" (S8).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2 - Adapting to the Challenge: How Much to Prepare and What to Do Spontaneously\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe students reported that they encountered different difficulties or unexpected events in each SPC. Some tried to prepare in advance to reduce these challenges, but challenges also arose during the preparation itself. They described feedback as a “\u003cem\u003eshared resource\u003c/em\u003e” (S7) that helped them work through these difficulties together. For example, one student explained,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eFor my SPC, I had just written down a few questions, and I didn’t really look at them much. I think it was very important for me to go in sort of unprepared, because that’s how it will be as a doctor when patients come to you. That’s what I was trying to practice—going in a bit less prepared and going with the flow of the conversation, rather than preparing so much that I couldn’t deviate when the conversation naturally took a different direction. I think it’s not always necessary to prepare in advance, because the feedback is, in a way, a shared resource that already helped me shape the talk. That’s also the kind of feedback I would give to my peers.\u003c/em\u003e\" (S10)\u003c/p\u003e\u003cp\u003eAnother student mentioned,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003ePreparing notes doesn’t always help, since you can’t predict what the SP will say. The SPC isn’t a fixed recipe—it changes from case to case. Notes can feel reassuring, but it’s easy to rely on them too much, even when they’re not truly useful. One of my learning goals is to handle the consultation without depending on notes, because SPC is about simulating real-life scenarios, and it needs to feel authentic\u003c/em\u003e.” (S3)\u003c/p\u003e\u003cp\u003eThe students reported that they took notes during SPCs, using either laptops or paper. They emphasized that both note-taking and typing skills were important. Many students mentioned struggling with these skills, explaining that they often found it “\u003cem\u003edifficult to keep up with note-taking while taking the patient’s history\u003c/em\u003e” (S7). For example, one student stated,\u003c/p\u003e\u003cp\u003e“\u003cem\u003eTaking doctor notes to document your thoughts and what the patient is saying can disrupt the flow — especially when typing, which is harder than writing on paper. Still, you know you have to learn to type, listen, and respond all at once. It’s just difficult right now. Over time, I’ve learned to adapt to the unexpected during SPCs\u003c/em\u003e.” (S5)\u003c/p\u003e\u003cp\u003eanother student mentioned,\u003c/p\u003e\u003cp\u003e“I don’t think it’s correct to tell the patient to slow down and wait for me to take notes. It is difficult to keep up with note-taking while taking the patient’s history. Some of the patient very nicely wait for me, but some patients start to repeat key words just to accommodate my writing speed, which feels awkward for me.” (S7)\u003c/p\u003e\u003ch2\u003eTheme 3 - Reflections to Automate Actions and Consultation Structure\u003c/h2\u003e\u003cp\u003eThe students reported that as they participated in more SPC sessions, they became more familiar with the structure of medical consultations. They reflected that “\u003cem\u003eAfter internalizing the three consultation phases, communication skills improved more quickly\u003c/em\u003e” (S1). For example, one student mentioned,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eNow, at the third SPC, and having received so much feedback on how to structure my SPCs during the tutorial discussions, I would say that I am just beginning to internalize the structure of the consultation process.\" (S3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe students reported that over time, their focus shifted from detailed learning goals to concentrating more on the overall consultation structure. They explained that they wanted their consultations to feel “\u003cem\u003enatural while remaining structurally clear enough\u003c/em\u003e.” (S4). For example, one student noted,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eIt (the consultation structure) helped me in the sense that I knew what a consultation should look like, because, for example, for the first two SPCs. I was just extremely focused on everything I was saying, and absolutely everything I was doing. But in later SPCs, I just learned what things I don't need to focus on anymore (structured phases of a consultation), because I was doing it naturally, when I am the doctor in the SPC, the structure of how to conduct a consultation becomes clear enough that I no longer need to follow external guidance\u003c/em\u003e.\"(S4)\u003c/p\u003e\u003cp\u003eThe students reported that time management was important for maintaining the consultation structure. They shared their thoughts on why time management can be challenging, “\u003cem\u003ehow much time to give patients to share their concerns” (S10)\u003c/em\u003e. Another student also noted that,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Sometimes I talk just to fill the silence because I’m unsure what to ask. I end up asking random questions simply to avoid awkwardness with the SP.\"\u003c/em\u003e (S7)\u003c/p\u003e\u003cp\u003eThe students also reported that they learned to use their time wisely by asking “\u003cem\u003ea mental listed of questions\u003c/em\u003e” (S5) rather than random ones. They explained that this helped make their communication more efficient. For example, one student said,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I mentally check my detailed list of history taking items and ask the patient. In earlier sessions, I asked too many random questions that didn’t follow a clear path—it took time to rule things out one by one. Random questions aren’t time-efficient, since you never know if the SP will give a long story or just say no. You really need to ask to the point questions and having a mental list, helps to pick the relevant ones.\"\u003c/em\u003e (S9)\u003c/p\u003e\u003ch2\u003eTheme 4 - Dealing with the Bottleneck: Emotions are Heavy and Silent\u003c/h2\u003e\u003cp\u003eThe students reported that when reflecting on their SPC experiences, they often felt like novices. For example, one student mentioned,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I still feel like a novice in consultations—my own thoughts distract me, making me focus too much on the medical issue and miss subtle patient cues, like hesitation or emotion. I shared this in the tutorial, and others felt the same.\"\u003c/em\u003e (S8)\u003c/p\u003e\u003cp\u003eStudents discussed the skill of persuading patients about antibiotic use, especially when patients are swayed by family stories or past experiences. Many students shared their experiences; for example, one student said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I had a patient who insisted on antibiotics because they mentioned that their family had successfully used them in the past for similar symptoms. They were convinced that antibiotics were the only solution. I had to explain that each case is different and that antibiotics are not always necessary. I emphasized the importance of not overusing antibiotics to avoid resistance and explained the potential risks. It was challenging, but I tried to be empathetic and provide clear, evidence-based information to help them understand.\"(S7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe students reported that patients’ strong emotions or demands sometimes left them momentarily quiet or at a loss for words. Although this was a rare experience, they recognized it as something they needed to learn to manage. Several students recalled moments when they became silent after feeling overwhelmed by a patient’s strong feelings or requests. For example, one student noted,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003ePatients often come in with strong beliefs about their symptoms, which can be misleading, and they give you emotional pressure to control the talk. This threw me off and made it hard to stay in control of the conversation. In one case, the SP just wanted a sick note, and later pointed out that I focused too much on medical details instead of seeing the bigger picture\u003c/em\u003e.\"(S5)\u003c/p\u003e\u003cp\u003eThe students reported that empathy played a key role in their SPC performance, especially in helping them improve further. Several shared that they invested more emotional effort to improve their communication and described how they learned to express empathy appropriately. For example, one student mentioned,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eYour attitude towards the SP is important; it can really affect how well the consultation goes. Being genuine is a big part of it, but empathy is more than just being real. You gotta listen, really listen, and show you care about what they’re going through. Sometimes, you just need to pause and think about what they said before you respond. That’s why it works with some patients and not with others. It’s not just about being a doctor; it’s about humanistic characteristics and helping the patient feel heard\u003c/em\u003e. (S6)\u003c/p\u003e\u003cp\u003eThe students reported that being natural in their communication—treating patients as people rather than just cases—was essential for improving and overcoming challenges. One student added,\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eI always try to be as much myself as possible, while of course following a certain structure for the consultation so in that sense, maybe it’s not completely free or natural dialogue, but this is the way I’ve found helpful in letting the patient share their complaints with me. You don’t always take them as client or a problem to solve. They are humans with emotions\u003c/em\u003e.\" (S8)\u003c/p\u003e\u003cp\u003eThe observational data corroborated and enriched the themes identified through the thematic analysis of the interview transcripts, indicating strong convergence between self-reported experiences and observed behaviours. Across simulated patient consultations (SPCs), observer noted patterns of behavior that aligned closely with students’ expressed feedback preferences and learning strategies. In some cases, the observations also illuminated subtle, unspoken aspects of feedback use – such as non-verbal reassurance seeking, time management adaptations, and emotional self-regulation – that students did not explicitly articulate in interviews.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents those four overarching themes, each accompanied by representative observation notes. Within each theme, subcodes illustrate specific behaviors, from reliance on tutor guidance in early consultations to increasingly autonomous structuring of patient interactions. Together, these data provide a multi-faceted view of how students navigate stress, adapt preparation strategies, internalize consultation frameworks, and manage the emotional demands of patient communication.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and Representative Quotes Identified from Observation Notes.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes and codes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuote from the observation notes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 1 - Navigating stress: The dynamics of feedback utilization and learning choices\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReliance on Teacher Guidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“In the tutorial discussion, the student paused mid-sentence, looked at the tutor, and waited. The tutor said, ‘It’s okay to make mistakes.’ The student nodded and continued explaining their consultation choices.” (Obs 1, S1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeer Comparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“During the group discussion, the student said they had tried to use the same opening question that another peer had used in the previous SPC because it seemed to work well.” (Obs 5, S5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOversight of minor details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“When reflecting on their SPC, the student admitted forgetting to close the door after the SP entered. Another student reminded them, and the group laughed.” (Obs 4, S4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoherence in Consultations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“In the discussion, the student described how their questions in the SPC followed one another more smoothly than before, crediting a tip from the previous tutorial.” (Obs 3, S10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 2 - Adapting to the challenge: How much to prepare and what to do spontaneously.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBringing notes and scripts for confidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student held a handwritten list of questions during the discussion and explained it was the same one they had used in the SPC to help keep on track.” (Obs 2, S2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNote-taking during the SPC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“In the group, the student said they had jotted down key words while the SP was speaking and that this approach came from a peer’s earlier suggestion.” (Obs 4, S8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaking summaries after each phase of the consultation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student described summarizing the patient’s history in the SPC and said this was a technique they had learned from feedback in the previous tutorial.” (Obs 5, S7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 3 - Reflections to automate actions and consultation structure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGoing quicker from novice to expert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student told the group they had started the SPC hesitantly but became more confident as it progressed, which they linked to practising tips from earlier discussions.” (Obs 3, S3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternalizing the consultation structure and the three phases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“Without prompting, the student described moving through history-taking, diagnosis, and management in their SPC, noting this matched the structure discussed in tutorials.” (Obs 2, S9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“In the discussion, the student said they kept an eye on the clock during the SPC so they could finish all sections on time, a suggestion they credited to a peer.” (Obs 6, S4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelevant question asking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student explained that in the SPC they set aside their checklist and asked follow-up questions based on the SP’s responses, as recommended in a previous tutorial.” (Obs 4, S5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 4 - Dealing with the bottle neck: emotions are heavy and silent.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReacting correctly towards the patient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student recounted that when the SP became frustrated, they softened their tone and rephrased questions, a technique they had practised during role-play in the tutorial.” (Obs 4, S4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHanding strong emotions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“During the discussion, the student described pausing and taking a breath when delivering difficult news in the SPC, something they said was suggested by the tutor.” (Obs 3, S6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmpathizing appropriately\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student said they had leaned forward and responded to the SP’s personal story with, ‘That sounds very difficult for you,’ which they had tried after SP feedback from an earlier session.” (Obs 6, S5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersuading the patient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e“The student told the group they used an analogy to explain why antibiotics were not needed, an idea they said came from their buddy during preparation.” (Obs 5, S1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored how medical students perceived and engaged with different sources of feedback\u0026mdash;buddies, simulated patients (SPs), video annotations, and tutorial discussions\u0026mdash;across four simulated patient consultation (SPC) sessions, and how these perceptions changed over time. Drawing on cognitive load theory (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and feedback sense-making (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), the results indicate that students\u0026rsquo; feedback preferences shifted over the course of the four SPCs in ways that generally corresponded with changes in their familiarity with the task and developing communication skills. The four identified themes\u0026mdash;\u003cem\u003eNavigating Stress: the dynamics of feedback utilization and learning choices\u003c/em\u003e, \u003cem\u003eAdapting to the Challenge : how much to prepare and what to do spontaneously, Bringing notes/scripts for confidence\u003c/em\u003e, \u003cem\u003eReflections to automate actions and consultation structure\u003c/em\u003e, and \u003cem\u003eDealing with the Bottleneck: emotions are heavy and silent\u003c/em\u003e\u0026mdash;help explain these shifts and underscore the interdependent roles of feedback and cognitive management in learning complex communication skills.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eResearch Question 1: Perceived Value of Feedback Sources Across SPCs\u003c/h2\u003e\u003cp\u003eThe patterns reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e show that after the first SPC, students valued simulated patient feedback most highly, followed by tutorial discussions, student-buddy feedback, and finally annotation feedback. This preference is consistent with \u003cem\u003eTheme 1: Navigating Stress: the dynamics of feedback utilization and learning choices\u003c/em\u003e, where students described feeling anxious and uncertainty during their initial SPCs. Feedback from SPs was perceived as most authentic and directly relevant, offering specific, patient-centered suggestions that helped students link their performance with the expectations of real consultations. The immediacy and realism of SP feedback appeared to provide an accessible starting point for making sense of their performance (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt the second SPC, the highest value shifted to student-buddy feedback, followed by SP feedback, tutorial discussions, and annotation feedback. Comments from students indicated that peer input felt relatable and encouraging, which may have helped reduce perceived pressure and normalized their learning challenges. This aligns with \u003cem\u003eTheme 2: Adapting to the Challenge: how much to prepare and what to do spontaneously\u003c/em\u003e, where feedback functioned as a collaborative shared resource, helping students navigate the unpredictability of consultations and exchange practical improvement strategies.\u003c/p\u003e\u003cp\u003eBy the third SPC, student-buddy feedback remained the most valued, followed by tutorial discussions, annotation feedback, and SP feedback. At this stage, students expressed more comfort with peer critique and placed increasing emphasis on tutor guidance and discussions in the tutorial session to refine their performance, consistent with \u003cem\u003eTheme 3: Reflections to automate actions and consultation structure\u003c/em\u003e. As they became more familiar with the consultation structure, students appeared better able to engage with multiple feedback sources, including annotation feedback, to support reflection and skill refinement (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt the fourth SPC, tutorial discussions were rated highest, followed by annotation feedback, student-buddy feedback, and SP feedback. This shift suggests a greater reliance on structured, integrative feedback to reflect, while the reduced emphasis on SP feedback likely reflects increased confidence in meeting patient interaction expectations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eResearch Question 2: Reasons Behind Shifts in Feedback Perceptions\u003c/h2\u003e\u003cp\u003eThe shifts in feedback preferences can be understood through the interplay of students\u0026rsquo; developing familiarity with SPCs, evolving cognitive load management and capacity for feedback sense-making.\u003c/p\u003e\u003cp\u003eInitially, high stress and lack of familiarity created a heavy cognitive load (\u003cem\u003eTheme 1 \u0026ndash; Navigating stress: the dynamics of feedback utilization and learning choices\u003c/em\u003e), limiting students\u0026rsquo; ability to process more complex or less immediate feedback. This was especially evident in early simulated patient consultations (SPCs), where students described feeling \u0026ldquo;extremely stressed\u0026mdash;almost panicking\u0026rdquo; (S1) and even considered stopping the consultation altogether. Such intense emotional responses made it difficult for students to focus on nuanced feedback or reflect deeply during the session. In these moments, feedback that was concrete, immediately relevant, and clearly linked to observable behaviors was easier to act upon than feedback that required delayed reflections. In this context, SP feedback provided direct, relevant pointers that helped clarify learning goals. For example, one student noted that they viewed the SP as \u0026ldquo;a kind of tutor\u0026rdquo; whose feedback was \u0026ldquo;helpful and felt accurate,\u0026rdquo; (S8) especially in identifying mistakes during the simulation. Because SP comments often mirrored the patients\u0026rsquo; real-time reactions-such as noting when an explanation was unclear or when empathy was missing-students could immediately adjust their communication strategies in subsequent role-plays or even within the same SPC. This immediacy and relevance made SP feedback more accessible and actionable under stress, helping students to priorities essential communication steps and regain a sense of control over the consultation.\u003c/p\u003e\u003cp\u003eIn contrast, less interactive feedback\u0026mdash;such as video annotations\u0026mdash;was less frequently used or valued early on. Students reported that although these annotations contained useful insights, they were often received too late to be acted upon in the same SPC, making them harder to integrate under pressure. They were often too overwhelmed to engage with delayed or abstract forms of feedback. As one student shared, \u0026ldquo;I was so focused on asking the right questions that I forgot to summarize the patient\u0026rsquo;s responses,\u0026rdquo; (S8) and only realized the mistake after peer feedback provided a simple, structured tip. This example illustrates that peer feedback, when offered immediately after the consultation, was more likely to result in quick behavioral adjustments than delayed, and through non-interactive sources. This highlights how real-time, interactive feedback was more effective in helping students manage cognitive load and improve performance during early SPCs.\u003c/p\u003e\u003cp\u003eAs students became more comfortable (\u003cem\u003eTheme 2 \u0026ndash; Adapting to the challenge: how much to prepare and what to do spontaneously\u003c/em\u003e), they began to engage more actively with peer feedback, recognizing it as a source of reassurance and practical guidance. This collaborative interpretation of feedback appeared to help students manage uncertainty and focus on targeted improvements (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). One student described feedback as a \u0026ldquo;shared resource\u0026rdquo; (S10) that shaped their consultation approach and was also something they offered to peers. In these later discussions, peers were not just recipients of advice but co-constructors of strategies, helping one another adapt to both predictable and unexpected moments in the consultation. This framing highlights how feedback evolved from a one-way input into a mutual learning tool.\u003c/p\u003e\u003cp\u003eIn later SPCs, greater familiarity and partial automation of consultation routines allowed students to shift their focus from rigid preparation to adaptive communication. For instance, one student reflected, \u0026ldquo;I think it\u0026rsquo;s not always necessary to prepare in advance, because the feedback is, in a way, a shared resource that already helped me shape the talk\u0026rdquo; (S10). Another added, \u0026ldquo;The SPC isn\u0026rsquo;t a fixed recipe\u0026mdash;it changes from case to case,\u0026rdquo; (S3) emphasizing the need for flexibility over scripted responses. Here, peer and tutor feedback together provided the scaffolding for students to experiment with spontaneous communication while maintaining overall structure, reflecting a shift in the perceived value of these sources toward fine-tuning rather than basic skill acquisition.\u003c/p\u003e\u003cp\u003eStudents also began to recognize and address practical challenges collaboratively, such as note-taking during consultations. One student explained, \u0026ldquo;Taking doctor notes\u0026hellip; can disrupt the flow\u0026mdash;especially when typing,\u0026rdquo; but noted that over time, they learned to \u0026ldquo;adapt to the unexpected during SPCs\u0026rdquo; (S5). Observations from tutorial discussions showed that these exchanges often included concrete peer-generated tips\u0026mdash;such as alternative ways to capture information without breaking rapport\u0026mdash;which students reported implementing in subsequent SPCs. These shared experiences and peer strategies helped students navigate the evolving demands of SPCs with greater confidence and authenticity (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn later SPCs, greater familiarity and partial automation of consultation routines (\u003cem\u003eTheme 3 \u0026ndash; Reflections to automate actions and consultation structure\u003c/em\u003e) freed cognitive resources for engaging with more detailed and self-directed feedback. Students reported that internalizing the structure of medical consultations helped streamline their communication. As one student reflected, \u0026ldquo;After internalizing the three consultation phases, communication skills improved more quickly\u0026rdquo; (S1), while another noted, \u0026ldquo;I am just beginning to internalize the structure of the consultation process\u0026rdquo; thanks to repeated feedback during tutorial discussions (S3). In these cases, tutor feedback played a central role in reinforcing core structures, while peer discussion helped personalize and contextualize the application of these structures in varied cases.\u003c/p\u003e\u003cp\u003eThis growing familiarity allowed students to shift their focus from granular learning goals to maintaining a natural yet structured flow. One student explained, \u0026ldquo;In later SPCs, I just learned what things I don't need to focus on anymore\u0026hellip; because I was doing it naturally\u0026rdquo; (S4). This sense of automation enabled students to engage more meaningfully with tutor and peer feedback, which became particularly valuable for refining finer points of communication. Video annotation feedback, which had been used less often earlier, now gained relevance as students had the cognitive space to revisit their performance and apply nuanced corrections.\u003c/p\u003e\u003cp\u003eTime management also emerged as a key skill that developed alongside structural familiarity. Initially, students struggled with pacing, sometimes asking \u0026ldquo;random questions simply to avoid awkwardness\u0026rdquo; (S7). However, with experience, they began using mental checklists to guide their questioning more efficiently. As one student shared, \u0026ldquo;Having a mental list helps to pick the relevant ones\u0026hellip; Random questions aren\u0026rsquo;t time-efficient\u0026rdquo; (S9). This improvement was often driven by targeted advice in tutorial discussions and, at times, by annotation feedback that drew attention to how students used their time during the consultation. This evolution in strategy reflects how annotation feedback and tutorial discussions supported purposeful self-review and helped students refine their consultation techniques.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTheme 4 \u0026ndash; Dealing with the bottleneck: emotions are heavy and silent\u003c/em\u003e highlights that emotionally demanding scenarios\u0026mdash;such as handling resistance or strong emotions\u0026mdash;still required support. Students frequently described feeling like novices, with one noting, \u0026ldquo;My own thoughts distract me, making me focus too much on the medical issue and miss subtle patient cues, like hesitation or emotion\u0026rdquo; (S8). These moments of uncertainty were often shared in tutorial discussions, which offered a safe space for sense-making and rebuilding confidence. In these moments, feedback from the tutor was often instrumental in reframing challenges and offering communication strategies, while peers provided empathy and shared coping tactics.\u003c/p\u003e\u003cp\u003eTutorials also helped students navigate emotionally charged consultations, such as persuading patients about antibiotic use. One student recounted, \u0026ldquo;I had to explain that each case is different and that antibiotics are not always necessary\u0026hellip; I tried to be empathetic and provide clear, evidence-based information\u0026rdquo; (S7). In this case, SP feedback on patient perspective combined with tutor input on phrasing strengthened the student\u0026rsquo;s ability to respond effectively in real time (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). These experiences underscored the emotional as well as cognitive role of feedback, especially when students felt overwhelmed or momentarily at a loss for words.\u003c/p\u003e\u003cp\u003eStudents recognized that empathy was central to managing these challenges. As one student put it, \u0026ldquo;Empathy is more than just being real\u0026hellip; You gotta listen, really listen, and show you care\u0026rdquo; (S6). Another emphasized the importance of treating patients as people, not just cases: \u0026ldquo;They are humans with emotions\u0026rdquo; (S8). Feedback from SPs was particularly valuable here, as it provided insight into whether empathy was actually perceived by the patient, giving students an external validation of their intentions. These reflections show how tutorial discussions supported the development of humanistic communication skills, helping students move beyond technical competence toward emotionally intelligent practice (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOverall, the results suggest that feedback preference evolved systematically alongside students\u0026rsquo; progression in SPCs, reflecting their changing cognitive and emotional needs rather than arbitrary variation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eImplications\u003c/h2\u003e\u003cp\u003eThe findings of this study carry important implications for medical education practice. First, the clear, stage-based shifts in students\u0026rsquo; feedback preferences reinforce the need for feedback approaches that are both flexible and developmentally responsive. Educators should adapt feedback delivery over time, aligning it with learners\u0026rsquo; evolving cognitive load management abilities and emotional readiness. Early-stage learners benefit from authentic, patient-centered feedback that helps them navigate uncertainty and clarify performance expectations, while more advanced learners require feedback that deepens reflection, supports self-regulation, and strengthens professional identity. Second, the increasing importance of peer feedback and tutorial discussions in later stages highlights the value of structured, collaborative learning opportunities. Incorporating purposeful peer-to-peer interaction alongside expert-guided reflection can enhance learners\u0026rsquo; ability to interpret complex feedback and internalize advanced communication skills. Medical curricula should therefore scaffold feedback opportunities, moving intentionally from highly guided, externally focused input toward learner-driven, reflective, and peer-supported feedback ecosystems.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study provides valuable insights but has limitations. The small, single-institution sample may limit the generalizability of findings; multi-site studies with diverse student cohorts are needed to capture broader feedback experiences. Additionally, while this study focuses on SPC-related feedback, students\u0026rsquo; communication skill growth may also have been influenced by concurrent curricular or clinical learning experiences not examined here.\u003c/p\u003e\u003cp\u003eThe cross-sectional design\u0026mdash;capturing snapshots at each SPC\u0026mdash;limits the ability to follow individual developmental feedback trajectories. Longitudinal research could more precisely track how feedback preferences and sense-making evolve within the same learners over time. Finally, this study did not examine how feedback mode or delivery style (e.g., dialogic vs. unidirectional) might influence interpretation and integration; future research should address these factors.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eFuture Directions\u003c/h2\u003e\u003cp\u003eBuilding on these findings, future research should examine the long-term impact of varied feedback strategies on medical students\u0026rsquo; professional development and communication skills, following learners into clinical training and practice. Studies extending beyond simulated settings into authentic patient care contexts would clarify how feedback habits transfer to real-world environments. Comparative research across different medical schools, specialties, and cultural contexts could inform more tailored feedback approaches. In addition, as technology becomes more embedded in medical education, investigating the role of digital modalities\u0026mdash;such as enhanced video annotations, immersive simulations, and AI-supported feedback\u0026mdash;could identify ways to optimize cognitive load while promoting deep reflection. Such work will support the creation of adaptive, evidence-based feedback systems that evolve alongside learners\u0026rsquo; developmental stages and cognitive capacities.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that medical students\u0026rsquo; feedback preferences during simulated patient consultations change in predictable ways that mirror their growth in communication competence and cognitive load management. Initially, SP feedback provides emotional reassurance and concrete guidance, but as learners\u0026rsquo; confidence and self-regulation increase, they shift toward valuing peer insights, structured tutorial dialogue, and eventually self-directed video annotation. These changes reflect a move from external validation toward autonomous, cognitively rich feedback engagement. Designing feedback practices that anticipate and support these developmental shifts can better equip medical students to manage cognitive demands, make sense of complex input, and continually refine communication skills\u0026mdash;ultimately improving patient care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSPC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003esimulated patient consultation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.Y., M.A. and J.v.M. conceived the presented idea. M.A., S.E.K and J.v.M. verified the analytical methods. H.Y. and Z.L. analyzed the data. H.Y. drafted the manuscript under the supervision of M.A. and S.E.K.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe regretfully note that Professor Jeroen J. G. van Merri\u0026euml;nboer passed away during the preparation of this manuscript. His contributions to the conceptualization and early development of this work were invaluable. We are deeply grateful for his guidance and insights, which have left a lasting impact on our research.\u003c/p\u003e\n\u003cp\u003eWe appreciate SkillsLab Coordinator Consult Ingrid Caubergh for taking the time to provide additional feedback on the manuscript. We appreciate the connections that SkillsLab Sandy Nelissen - Graven has been given to make sure the data authorization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHao Yu \u003cimg src=\"data:image/png;base64,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\" alt=\"image\" width=\"34\" height=\"34\"\u003e\u0026nbsp;https://orcid.org/0000-0002-0821-8018\u003c/p\u003e\n\u003cp\u003eZhien Li \u003cimg src=\"data:image/png;base64,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\" alt=\"image\" width=\"34\" height=\"34\"\u003e\u0026nbsp;https://orcid.org/0009-0007-2223-8940\u003c/p\u003e\n\u003cp\u003eS. Eleonore K\u0026ouml;hler \u003cimg src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAACIAAAAiCAMAAAANmfvwAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAGPUExURQAAAI7GHJ3YJ6TIJJm7IqrMIqLRLpvILKbIN6bTN5/KNaTPNajPNaHLNKXLNKfRNqPPNKPPOKfPOKfTNKHMM6XQM6PLOKPOOKbQNaLON6PKNabNNaTNN6PLNqPNNqTMNqXMNaXPNajMN6bNN6TON6PLNqXNNqXNOKbNNqXOOKTMN6bONaXNN6bONabOOKTLN6TNOKXNOKTON6bON6XNOKXON6XOOKXNN6XON6bNN6XNOaXOOKXON6XNN6bNOKbOOKXNOKTMOKXNOKXOOKXNN6XOOKXNOKXNOKbOOajPP6vQRazRR63RSa3SS67SS67STK/STq/ST6/TTrHTUrHTVLLUU7LUVbLVVbbXXrfXX7jYZLrZZ73abr3bbb/ccMHddMXff8jhhs3ikM3kkc7klM/klNDll9HlmtLmm9LmnNTnoNbnpNbopNfoptfpp9fpqNrqrdzrs93ss97ttuPvwuXxxefxyufyy+jyzenzzevz0+v01O311+312fP45vj78Pz9+f7+/P7+/f7+/v///0prkAQAAABIdFJOUwAJDQ4PDxYXFxcYNTU2Nj1AQEBAQUFOTlZYYWFrbGxtb29vcHOAgICkpaanvr+/xsfHycnKy8zNzdDm7O339/f4+fn6+/z9/hdaNisAAAAJcEhZcwAAIdUAACHVAQSctJ0AAAGiSURBVDhPbZT5X1JREMUnLBUsl1aLXNI2IaECi0AEZbvYTtGmpqWVpraXC2oK9w/vMnNI3oXvL+fMmfMDH968R3W09/vC0WQyGvJdbEXkpOdWRv0nE+xBfIgrlMMW5MIurED3BDZ1TJzGkhlEanEJa8MVRA1cRoF6efz69xmrg7PScKd40nqd1cGUmytjMq1sPRTj4E610ZHF1JTscVMJYFj79Uipb3+qfFm8j1CpUaKWNHxJF5Xa0UJl7zXi9BG6AFurzOfz+eJnU3qH3EvX4WqVtzJ9rOhX4kborhi7olb1hpgIxcQ0VKYP9BM2MYqzGqyK2tYzrHGaZDXYlU09xxqncVaDXdnVb1hjdI/VYFWelvVjNhHysRqsynf9W8xIw1+Hyntdfi7OS8esB7BQKBReftB6f1bi9FGiG2JrFaFceoE4YJ70CRzDp58PlFr+wSzJLzVkO6sHg5NqDp8UeeQwm5LycIXOY27COWkQXUXQwDUUDEOILIaxZk4lkNaROIMlcN22X/ug9dobTt50fDy6EDtxD/j5ExT297UhIiL6B1qgGgRZLwxSAAAAAElFTkSuQmCC\" alt=\"image\" width=\"34\" height=\"34\"\u003e\u0026nbsp;https://orcid.org/0000-0003-1977-9977\u003c/p\u003e\n\u003cp\u003eMaryam Asoodar \u003cimg src=\"data:image/png;base64,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\" alt=\"image\" width=\"34\" height=\"34\"\u003e\u0026nbsp;https://orcid.org/0000-0001-6044-6790\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll students and patients volunteered to participate in the study and signed consent forms.\u003c/p\u003e\n\u003cp\u003eWritten informed consents were obtained from all students and simulated patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Review Committee of the Faculty of Health, Medicine and Life Sciences, Maastricht University (FHML-REC/2021/104).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available according to the participation consents. However, they are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no established conflicting financial interests or personal relationships that may have influenced the research presented in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was funded by SURF.nl (project number: OO20-17) and the School of Health Professions Education (SHE) at Maastricht University. H. Y. was supported by a scholarship granted by the China Scholarship Council (CSC, 202008440338)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKurtz S, Draper J, Silverman J. 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Bates' guide to physical examination and history-taking: Lippincott Williams \u0026amp; Wilkins; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNayman C, Do J, Goodbaum A, Eady K, Moreau K. The perceptions and experiences of medical students in a pediatric buddy program: a qualitative study. BMC Medical Education. 2022;22(1):240.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Thematic analysis: American Psychological Association; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacLaine TD, Lowe N, Dale J. The use of simulation in medical student education on the topic of breaking bad news: A systematic review. Patient Education and Counseling. 2021;104(11):2670\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorowczyk M, Stalmach-Przygoda A, Doroszewska A, Libura M, Chojnacka-Kuraś M, Małecki Ł, et al. 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BMC Medical Education. 2023;23(1):645.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"simulated patient consultations, student-buddy feedback, simulated patient feedback, video annotation feedback, tutorial discussions","lastPublishedDoi":"10.21203/rs.3.rs-7426383/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7426383/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study explores the evolution of first-year international medical students' perceptions of feedback as they develop communication skills through simulated patient consultations (SPCs). Knowing how students’ appreciation of feedback evolves over time is essential for improving feedback methods in medical education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this qualitative 36-week study, we followed ten students, collecting data through closed questions assessing feedback perception, observation notes, and semi-structured interviews to document students' emotions and subjective reactions to feedback.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings indicate a gradual change in the importance students place on various feedback during their SPCs. Initially, feedback from simulated patients was highly valued due to its direct relevance to patient interactions and the students' focus on reducing their learning load. Data analysis revealed that as students progressed in their studies, the frequency of students using student-buddy feedback increased. By the final SPC, students reported that tutorial discussions had become their most trusted and reliable source of feedback. The analysis of the interviews also revealed four predominant themes that shed light on why their perceived values of feedback changed over time: navigating through stress, adapting to the challenge, enhancing the learning efficiency, and listening to the full story.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study reveals how medical students' views on the value of feedback evolve through simulated patient consultations, initially valuing patient feedback, then shifting to peer insights, and eventually to tutorial discussions. This progression reflects the students' growing skills in communication and their adaptation to the challenges of SPCs. The findings emphasize the importance of tailoring feedback strategies to the students’ developmental stages in medical communication learning during consultations, thereby enhancing the acquisition and retention of these skills. More broadly, this study underscores the critical role of adaptive feedback mechanisms in professional education, suggesting that such tailored approaches could be beneficial across various disciplines where skill development and effective communication are essential.\u003c/p\u003e","manuscriptTitle":"From Value to Valued: International Medical Students' Changing Views on Feedback Perception and Application in Communication Learning","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:44:48","doi":"10.21203/rs.3.rs-7426383/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-22T16:46:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T16:52:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175493629597453271440174223107101539907","date":"2026-04-13T16:02:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-12T15:59:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25200412027194330674192839693556646873","date":"2026-03-12T14:26:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1617648455142192464758113562368284525","date":"2026-01-23T14:45:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327187813733833308188350519483921745341","date":"2026-01-22T23:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278674235795593960019209227858228326562","date":"2025-10-28T17:22:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T17:58:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-26T09:52:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-26T09:51:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Simulation","date":"2025-08-21T12:40:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c0bd623-013d-4240-8bcf-b0eed201aaf6","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T10:24:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 04:44:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7426383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7426383","identity":"rs-7426383","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}