Image courtesy: Ana Hategan
Feedback is an essential and core component of medical training and growth in residency, especially when implemented and executed effectively. As learners, we crave feedback. When done appropriately, it can be a source of immediate, inexpensive, focused learning that is readily available. Despite its historical influence on medical teaching, programs continue to struggle to implement a culture and process of transmitting effective feedback, separate from evaluation. Wood (2000) identifies two situations that result in deficient feedback: the infrequency with which trainees are closely observed performing a skill or participate in deep discussion with a mentor, and the unease felt by preceptors in delivering feedback.
How is feedback defined in the literature?
van de Ridder et al (2008) reviewed the literature defining feedback in medical education with the goal of proposing an operational definition of feedback in clinical education. They define feedback as “specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance” (van de Ridder, 2008). In other words, feedback is intended to narrow the gap between actual and desired performance resulting in improvement (Ramaprasad, 1983).
What is the relationship between feedback and assessment? See answer below.
- Formative assessment (e.g., feedback) is about providing feedback to students in order to support and enhance learning.
- Summative assessment (e.g., overall judgement) is about measuring students’ achievement with the purpose of grading or informing decision about progression.
Why is feedback important?
Feedback is essential for personal and professional development. In fact, trainees crave feedback and it contributes to a sense of improvement and mastery. The adage “see one, do one, teach one” depends on appropriate feedback to achieve the desired outcome. From clinical interviews to procedures, feedback helps improve and reinforce performance, efficiency, and competence (Hargreaves et al, 1997).
What are some challenges with delivering effective feedback?
As illustrated in Table 1, not all feedback is created equal. Some barriers to the delivery of effective feedback include:
- It is difficult to do well.
- It is double-edged in that it can reinforce and modify behaviour or result in demotivation (a component of burnout) and deterioration in performance if not managed carefully.
- Most teachers get little or no instruction in giving feedback.
- Teachers feel negative feedback can be pointless if there are no resources to help students improve.
- Fear of damaging their relationship with learners and wanting to avoid undermining learner’s self-esteem.
- Corrective feedback can feel awkward to communicate.
- Teachers do not want to appear critical.
- Learners can become defensive when offered corrective feedback.
|Table 1. Barriers to delivering effective feedback|
|Difficulty to do well|
|Double-edged nature: can reinforce good behaviours as well as demotivate|
|Lack of training in how to give effective feedback|
|Lack of resources for helping learners follow up on topics discussed during feedback session|
|Fear of damaging interpersonal relationship through providing corrective feedback|
|Awkwardness associated with giving corrective feedback|
|Not wanting to appear “too critical” or “harsh”|
|Encountering defensiveness among individuals receiving feedback|
How can we improve the process of giving and receiving feedback?
As shown in Table 2, several strategies can help improve the process of providing feedback (Cantillon & Sargeant, 2008; Veloski et al, 2006). These strategies include the following:
- Normalize it: Implement this as an everyday component of the teacher-student relationship so both trainers and trainees can expect it and manage its effects. This will mitigate defensive reactions among learners and encourage a comfortable bidirectional working relationship that fosters and welcomes feedback from students as well.
- Set expectations: clarify expectations and criteria against which performance will be assessed. This will help make sense of what good performance looks like to the teacher and helps students better evaluate the gap between actual and desired performance.
- Be specific: Feedback should be on specific behaviours rather than general performance.
- Example: “You asked a great clarification question about what the patient meant by 'good' and waited for the patient to finish her thought. Well done!” Versus “Great job with the interview!”
- Make it non-judgmental: Ground feedback in what was directly observed and present it in non-judgmental language.
- Example: “I noticed the patient looked uncomfortable when you asked her to clarify details about the traumatic experience; how could you have responded in a more patient-centred way?” Versus “You pushed the patient to talk about a recent trauma, which made her feel uncomfortable and at risk for re-traumatization. Why didn’t you ask permission first?”
- Timely: Offer feedback at the time of an event or shortly afterwards. When it seems awkward to share corrective feedback in front of patients or peers, provide it in private as soon as possible after the event.
- Focused: Limit topics to one or two items only to prevent overwhelming and/or demoralizing the learner.
- Balanced: Seek what the learners’ own perception of their performance was and their ideas for improvement. Encouraging learners to routinely appraise and correct their own performance helps reinforce lifelong learning.
- Stimulating: Feedback should catalyze changes in the learner’s thinking, behaviour, and performance. Ask the learner how he or she might incorporate feedback into practice to narrow the gap between actual and desired performance.
Suggestions for improving the feedback process
||Make it an everyday component of the teacher-student relationship
||Clarify expectations and criteria against which performance will be assessed
||Feedback should be on specific behaviours rather than general performance
|Make it non-judgmental
||Focus on what was directly observed and use non-judgmental language
||Offer feedback at the time of an event or shortly afterwards
||Limit topics to one or two items only
||Seek what the learners’ own perception of their performance was and their ideas for improvement
Encourage learners to routinely appraise and correct their own performance, which helps reinforce lifelong learning
||Ask the learner how he/she might incorporate feedback into practice to narrow the gap between actual and desired performance
How can you, the learner, ask for feedback?
- Identify the goals and objectives of the clinical experience you are participating in and clarify what the expectations are for you as a learner. Feedback should stem from comparing your performance and achievements to said goals, objectives, and expectations.
- Schedule time early in a rotation to meet with the preceptor to discuss these topics and plan for regular feedback sessions as appropriate.
- Be observed: First, request for a time to be observed. Feedback should be grounded in specific, observable behaviour so it is tangible.
- Informal feedback: Ask for on-the-fly informal feedback as soon as possible after the observed period and ask what you did well and what you could have done better.
- Get to the essence of feedback: Specifically discuss what you feel you did not do well and want to work on; which deficits in performance you did not otherwise detect; and how you plan to deal with the identified performance deficits.
- Be proactive about feedback. Plan for observation and feedback time.
- Ask early, consistently, and in the appropriate setting.
- Feedback is intended to inform your practice. If you do not receive it in a timely manner, you will not know what to specifically change or reinforce and you will not be able to practice/demonstrate a response to the feedback.
- Link the feedback to learning goals.
Try these methods of giving feedback
- Feedback Sandwich:
A “sandwich” that includes a corrective comment (what the learner should change) in between reinforcing statements (what the learners should continue doing) might make it easier for a learner to receive feedback without feeling embarrassed or offended.
- Reinforcing feedback should underscore a behaviour that strengthens performance, while negative feedback serves to correct behaviour to improve performance.
- “I like the way you screened the patient for depression. I noticed you didn’t ask the patient to elaborate when he mentioned having suicidal thoughts in the past. Finally, you remembered to ask about alcohol and illicit drug use. Great job!”
Two common mistakes teachers make with feedback sandwiches:
- Use the word “but” before introducing the corrective statement. “I like how you did X. But,…” Students might begin to ignore the positive comments and focus on what comes after the “but.”
- Concentrate on the positive, leaving less time or depth to discuss improvement in the areas that might need more attention. Click
here to learn more.
- Pendleton Model:
This is a four step process for establishing a conversation about performance between a teacher and a student:
- Learner states what was good about his or her performance.
- Teacher states areas of agreement and elaborates on good performance.
- Learner states what was poor or could have been improved.
- Teachers states what he or she thinks could have been improved.
- Reflective Feedback Conversation:
This consists of a modified approach that places a greater emphasis on learner’s own ability to recognize performance deficits and includes a discussion on how the learner plans to improve. See the example in Table 3.
Reflective feedback conversation method
|The teacher asks the learner to share any concerns he/she may have about the recently completed performance
||“Let’s review the surgery. Is there anything you have concerns about, that perhaps didn’t go as well as you had hoped?”
|The learner describes concerns and what he/she would have liked to have done better
||“I wasn’t happy with tumour resection; I found it very hard to prize it off the posterior wall of the bladder and it bled a lot.”
|The teacher provides views on the performance of concern and offers support
||“It was clearly difficult for you to create a plane of cleavage between the tumour and the bladder wall. I find this difficult too.”
|The teacher asks the learner to reflect on what might improve the situation
||“Is there anything you can think of that might work better, make it easier, or improve it for next time?”
The student responds: “Well I was a bit anxious and perhaps because of that I was rushing and working too quickly.”
|The teacher elaborates on the trainee’s response, correcting if necessary, and checks for the trainee’s understanding
|| “Yes, that’s a good point. I would encourage you to slow down at times like these and that allows you to be even more delicate in your approach. Another suggestion is to use a blunt dissection technique rather than a scissors dissection. Does that make sense to you?”
Did you know?
Studies show, your perception of feedback and the evaluation process profoundly influences the contribution it makes on your learning (Watling & Lingard, 2012).
- Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961. doi: 10.1136/bmj.a1961.
- Hargreaves DH, Southworth GW, Stanley P, Ward SJ. On-the-job training for physicians. London; Royal Society of Medicine Press; 1997.
- Ramaprasad A. On the definition of feedback. Behavioral Science. 1983;28(1):4-13.
- van de Ridder JM, Stokking KM, McGaghie WC, ten Cate OT. What is feedback in clinical education? Med Educ. 2008;42(2):189-97.
- Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback and physicians clinical performance. Med Teacher. 2006;28:117-28.
- Watling CJ, Lingard L. Grounded theory in medical education research: AMEE Guide No. 70. Med Teach. 2012;34(10):850-61.
- Wood BP. Feedback: A key feature of medical training. Radiology. 2000;215:17-19.