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) |
https://orcid.org/0000-0002-0821-8018