How biased are you? The effect of prior performance information on attending physician ratings and implications for learner handover


Learner handover (LH), the process of sharing of information about learners between faculty supervisors, allows for longitudinal assessment fundamental in the competency-based education model. However, the potential to bias future assessments has been raised as a concern. The purpose of this study is to determine whether prior performance information such as LH influences the assessment of learners in the clinical context. Between December 2017 and June 2018, forty-two faculty members and final-year residents from the Department of Medicine at the University of Ottawa were assigned to one of three study groups through quasi-randomisation, taking into account gender, speciality and rater experience. In a counter-balanced design, each group received either positive, negative or no LH prior to watching six simulated learner–patient encounter videos. Participants rated each video using the mini-CEX and completed a questionnaire on the raters’ general impressions of LH. A significant difference in the mean mini-CEX competency scale scores between the negative (M = 5.29) and positive (M = 5.97) LH groups (P < .001, d = 0.81) was noted. Similar findings were found for the single overall clinical competence ratings. In the post-study questionnaire, 22/28 (78%) of participants had correctly deduced the purpose of the study and 14/28 (50%) felt LH did not influence their assessment. LH influenced mini-CEX scores despite raters’ awareness of the potential for bias. These results suggest that LH could influence a rater’s performance assessment and careful consideration of the potential implications of LH is required.

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The authors thank Lesley Ananny, Katherine Scowcroft and the Research Support Unit at the Department of Innovation in Medical Education for their ongoing support. The authors also thank the Department of Medicine at the University of Ottawa for their participation in this project.


The authors thank the Department of Medicine at the University of Ottawa, the Canadian Association of Medical Education (CAME) and the Association of Medical Education in Europe for their financial support through the Wooster Family grant and research grant programme respectively.

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Corresponding author

Correspondence to Tammy Shaw.

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Ethical approval

The authors obtained ethical approval from the Ottawa Health Network Research Ethics Board (OHSN-REB).

Previous presentations

The authors have presented the results of this study at the University of Ottawa’s 2019 Meridith Marks Day local conference in Ottawa March 29, 2019, the 2019 Canadian Association of Medical Education (CAME) annual conference in Niagara Falls, Ontario April 14, 2019 and will present at the 2019 Association of Medical Education in Europe annual conference in Vienna, Austria August 27, 2019. The project is also Dr. Shaw’s M.Ed. thesis project at the University of Dundee (manuscript in progress).

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Appendix 1: Study design

See Table 5.

Table 5 Study design

Appendix 2: Mini-CEX form


Appendix 3: learner–patient clinical encounter videos

See Table 6.

Table 6 Description of medical issues, patients and learners used in learner–patient clinical encounter videos

Appendix 4: Learner handover form—example

The Program Director is now forwarding educational information about each learner based on previous evaluations (ITERs, written examinations, OSCEs) over the last 12 months. Here is the information about this learner for you to reflect upon.


Appendix 5: Post-video questionnaire—example of questions for groups A&B

  1. 1.

    What did you think was the purpose of this study?

  2. 2.

    Did you recognize any of the learners in the videos? If yes, which ones? If no, skip Questions 3&4.

  3. 3.

    On a scale of 1 (poor) to 10 (excellent), what was your impression of this (these) learner(s) prior to this session?

  4. 4.

    Did your former impression of this (these) learner(s) impact your assessment of the current performance?

You were provided with information about the learner. Please answer the following questions. Please elaborate on your answers.

  1. 5.

    How did you consider the learner handover/forward feeding information as you watched the video?

  2. 6.

    What information, if any, provided to you in the learner handover/forward feeding information was relevant to you in making assessment judgments? If so, in which instance? If varied with each video, please comment.

  3. 7.

    Did you feel the information provided was credible? Why or why not?

  4. 8.

    How do you think the learner handover/forward feeding information impacted your assessment?

  5. 9.

    What is your general opinion regarding learner handover?

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Shaw, T., Wood, T.J., Touchie, C. et al. How biased are you? The effect of prior performance information on attending physician ratings and implications for learner handover. Adv in Health Sci Educ (2020).

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  • Assessment
  • Bias
  • Competency-based medical education
  • Learner handover
  • Transitions