#73 Does first impression ‘matter’? And does it matter if I think about it?
-and does it matter if I think about it?
Episode host: Linda Snell
Next time you, as a clinical supervisor, rate a learner’s performance in a clinical setting, think about your first impressions of the learner. Do those impressions influence your judgments or contribute to any bias? Does your judgement change, despite your first impressions, if the learner’s performance changes? And does it make a difference if you think about it? Listen up for answers to these questions and more.
Episode Article
Wood, T. J., Daniels, V. J., Pugh, D., Touchie, C., Halman, S., & Humphrey-Murto, S. (2024). Implicit versus explicit first impressions in performance-based assessment: Will raters overcome their first impressions when learner performance changes? Advances in Health Sciences Education, 29(4), 1155–1168.
Episode notes
We all use first impressions—those immediate, instinctive judgments formed within seconds of meeting someone. These judgments, often referred to as “thin slices” or “zero acquaintance judgments,” are based on incomplete information and processed automatically with little conscious awareness. They’re a natural part of human interaction, but in the high-stakes context of health professions education, their impact can be profound.
The authors did an estensive description of earlier research in the subject:
First impressions matter in health professions education
Predictive of subsequent judgments: First impressions often influence later evaluations, such as teacher ratings, OSCEs, or Multiple Mini Interviews (MMIs).
Performance changes and bias: A learner’s initial performance may lead to over- or under-rating if that performance later improves or declines.
Context matters: Most prior research on first impressions has been conducted in exam contexts, such as OSCEs, rather than in real-world clinical settings.
Implications for CBME: In competency-based medical education (CBME), first impressions play a role in entrustment decisions. Early judgments (thin slices) and presumptive entrustment (non-acquaintance judgments) can shape critical decisions about learners.
Explicit vs. implicit judgments: The act of making a first impression explicit has been shown to influence subsequent ratings compared to situations where evaluations remain implicit.
Purpose
The paper aimed to explore two key questions:
- To determine what degree raters are influenced by their first impressions when learner performance changes in a naturalistic context (rather than in an OSCE).
- To determine if making a first impression judgment explicit affects subsequent ratings compared to a more natural (implicit) rating process.
Methods
The authors designed an experimental study with clinical supervisors from internal medicine, emergency medicine, and family medicine at two Canadian universities. Participants were divided into two groups:
The study compared two groups of clinical supervisors
Explicit First Impressions: Supervisors in this group paused the video after 60 seconds to provide a “First Impression Global Rating” (FIGR). This step required them to consciously evaluate their initial impression of the learner’s performance.
Implicit First Impressions: Supervisors in this group viewed the full video without interruption, allowing their first impressions to remain unspoken and implicit.
After completing their assigned tasks, both groups used a modified Mini-CEX to evaluate the full performance. The Mini-CEX (Mini Clinical Evaluation Exercise) is a widely used assessment tool in clinical education, involving multiple domains of performance (e.g., history-taking, clinical reasoning, communication skills) rated on a scale of 1 to 9.
Supervisors rated the same six pre-recorded trainee-patient interactions, staged to depict common clinical problems.
These cases represented three experimental conditions of trainee performance trajectories:
- Weak to strong.
- Strong to weak
- Consistently strong or weak.
Both groups completed a final global rating after watching the entire video.
Explicit First Impressions: These occur when a rater is consciously prompted to articulate or rate their initial judgment of a learner, typically early in an evaluation process. This process forces the rater to reflect on and make their first impression overt, potentially influencing how subsequent assessments are made.
Implicit First Impressions: These happen automatically and unconsciously, without the rater explicitly acknowledging or rating their initial judgment. The impression remains part of the rater’s internal thought process, potentially affecting their later evaluations in subtle ways.
Analysis of Data:
The study employed multiple statistical analyses, focusing on correlations between different ratings:
- The internal consistency of Mini-CEX item ratings across the six cases.
- Comparisons of FIGR (for the explicit group) with final global ratings.
- Comparisons of item ratings and global ratings across the explicit and implicit groups.
- Performance changes (e.g., weak-to-strong vs. strong-to-weak) and their influence on final ratings.
The sample size was set at 50 participants, divided equally between the explicit and implicit groups. However, the final analysis included data from 45 supervisors (25 in the explicit group and 20 in the implicit group), slightly below the target. While this minor shortfall introduces a theoretical risk of a Type II error (failing to detect a difference where one exists), the authors note that the observed results are robust and unlikely to be significantly altered by additional participants.
Reflections from the Hosts:
- The study’s design was rigorous, but the slightly smaller sample size and reliance on a simulated setting may limit generalizability to authentic clinical environments.
- The analysis reinforced prior findings, showing that supervisors adjust their judgments when presented with new performance data.
- The reliance on the Mini-CEX, while standard in clinical education, highlights known limitations of the tool, such as its tendency to produce highly correlated ratings across domains (suggesting potential Halo effects).
Results/Findings
The study yielded several noteworthy findings, contributing to the understanding of how first impressions influence workplace-based assessments:
Judgment Adjustments:
- In cases where a learner’s performance evolved (weak-to-strong or strong-to-weak), raters adjusted their final global ratings to align with the observed performance changes.
- This suggests that first impressions, while impactful, are not fixed and can be recalibrated based on new information.
Explicit vs. Implicit First Impressions:
- No significant differences were found between the final global ratings of the explicit and implicit groups.
- This indicates that requiring raters to articulate their first impressions explicitly did not influence their subsequent evaluations any more than natural, implicit processes.
Consistent Performance:
For learners with consistent performance (e.g., strong throughout), both explicit and implicit raters provided similar ratings, reinforcing the stability of evaluations when performance does not fluctuate.
Bias Toward Initial Performance:
- There was a subtle trend suggesting that initial impressions may have a greater impact when the starting performance is weak, as raters tended to adjust less drastically upward.
- This finding aligns with the psychological principle that negative first impressions can be harder to overcome.
PAPER Clips
Reassurance for Educators: The results are reassuring, showing that thoughtful clinical supervisors can adapt their judgments based on observed changes in learner performance, countering concerns about the rigidity of first impressions.
Operational Implications: The study supports the idea that explicit first impression ratings are unnecessary in routine assessment processes, as implicit judgments naturally evolve with new evidence.
Questions for Future Research:
- Demographic Data: The study did not collect demographic data about the raters (e.g., years of experience, clinical specialty), missing an opportunity to explore whether these factors influence first impressions or the ability to adjust them. Collecting such data is relatively straightforward and could add valuable depth to future studies.
- Mixed Methods Approach: Including qualitative elements, such as interviews or think-aloud protocols, could help answer some of the “why” questions that the study could not explore. For instance, why do some raters adjust their judgments more than others? What cognitive processes are involved in overcoming a poor initial impression?
- Social and Implicit Bias: Can first impressions influenced by social or cultural biases be mitigated through interventions, and how might these biases affect the calibration of judgments?Can implicit biases related to social or cultural factors be mitigated through targeted interventions?
- Authenticity of Settings: Extending the research to real-world clinical environments could reveal additional complexities not captured in the controlled simulation.
Reflections on Practical Applications:
Entrustment Decisions: First impressions, especially in competency-based medical education, can shape initial entrustment decisions. The ability to recalibrate judgments provides a safeguard against premature biases.
Learner Handover: The findings suggest that non-acquaintance judgments (e.g., a handover summary) may not strongly influence subsequent ratings, offering some reassurance about the objectivity of assessments over time.
Limitations of the Mini-CEX: While widely used, the study highlights the need for more nuanced tools to capture complex workplace dynamics and reduce potential Halo effects in ratings.45 raters
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