Giving Effective Feedback

The importance of feedback in the clinical education setting was first publicized in a seminal article by Ende in 1983, in which he poignantly declared that “without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all.” As much as feedback in the clinical setting is universally spoken of and expected from academic training programs for improving students’ and residents’ performances as they progress through their medical education, learners at many levels have voiced their concern with the lack of valuable feedback provided during their clinical education. As concluded by an ACGME 2013 resident survey, “satisfaction with feedback after assignments” had the third-lowest rating among all items assessed, such as appropriate duty hours and resident well-being. An AAMC 2012 medical student questionnaire revealed that as many as one-third of students did not agree that faculty provided sufficient feedback on their performance during clerkships (Weinstein, 2015). Some theorize that labeling feedback as such during discussion can lead to improved reception in learners, however others have argued that a more substantive approach to administering feedback is necessary.

Before delving into the specifics of giving feedback, it is important to understand the difference between feedback and evaluation. Feedback is surmised to be formative assessment, a non-judgmental and immediate assessment with the intent to improve a learner’s self-reflection and abilities over time to achieve a future goal. Evaluation, on the other hand, is a judgmental and longitudinal form of summative assessment with the intent to measure whether or not a certain level of competence has been achieved. Thus, it is important to realize that feedback is what students seek on a day-to-day basis to build their clinical skills over the course of a clerkship.

Several methodologies for giving feedback have been proposed, including Pendelton’s Method, the Feedback Sandwich, and the ALOBA-SET GO method that have been outlined in the literature over the last few decades. Regardless of which approach an individual chooses to apply to their clinical practice, the following recommendations are universally encouraged to improve effectiveness in delivering quality feedback:

1. Promote the educational alliance: Establish mutual goals and respect with the learner early on to welcome dialogue and educational exchange. Studies have demonstrated that source credibility, or respect for the source of feedback, plays a monumental role in the effectiveness and receptivity of feedback. The higher the level of respect for the educator, the more effective the feedback is in delivery, acceptance and application.

2. Set goals: Balance the learner’s objectives with the educator’s expectations early and clearly.

3. Well-timed: Provide feedback shortly after working with the learner – this will have more impact if both the learner and educator have fresh impressions of the clinical work performed.

4. Use first-hand account: Provide feedback that is based on direct observation of the learner’s performance – this will lead to more honest feedback and more concrete advisement of future steps to reach performance goals.

5. Elicit learner’s perception: Elicit learners’ perception of their performance prior to providing feedback to highlight their concerns and how they believe objectives established at the beginning of the clinical experience were achieved. This will help the educator share recommendations in the most beneficial fashion and provide an opportunity to assess performance perception discrepancies.

6. Focus on modifiable behaviors: Direct feedback toward the learner’s effort, knowledge, decisions, and actions rather than the individual’s abilities and personality traits – this will allow the learner to focus on areas that they are able to control and adjust rather than taking a personal hit on characteristics they have less ability to modify.

7. Assess performance based on standard level for learner: Compare the learner’s performance, regardless of how well or poorly performed, to a particular standard for their appropriate learning level. Many educators recommend use of Pangaro’s RIME mnemonic to assist in assessing learner’s milestones in the context of their learning cohort:

R – reporter

I – interpreter

M – patient manager

E – patient educator

8. Be specific: Provide specific and direct examples to support your feedback, whether positive or negative/constructive. This will make the feedback real and less formidable. Reinforce the behaviors, actions, attitudes that the learner did well, so he/she can continue to emulate them, along with providing more constructive feedback on needed improvements. 

9. Limit feedback:Specify one or two areas of improvement that the learner can work on for their next clinical experience. This will make the feedback more digestible, allow the learner to focus on specifics in their next experience without being overwhelmed at changing too much too quickly, and will allow for a more memorable and formative feedback session.

10. Be non-judgmental: Avoid evaluative or judgmental language. 

11. Create a concrete plan: Brainstorm concrete, actionable steps for the learner to undertake on his/her next clinical shift to improve performance. Try to avoid “you can do this better,” and instead attempt “try this next time.”

Many providers are hesitant to offer honest feedback due to lack of training in this clinical skill, as well as concern for demoralizing and deconstructing a learner’s self-esteem. For fear of undermining the mentor-mentee relationship, many may opt for a reiteration of positive attributes the learner displays over a more thoughtful, honest and formative session. It is important to note one’s personal barriers in giving feedback, and those outlined below are most common: 

Barriers:

  • Fear of upsetting the trainee or damaging the relationship
  • Unable to provide guidance on how to rectify behavior
  • Fear of inconsistent feedback from multiple sources
  • Inadequate relationship with the learner
  • Early students do not have the best self-reflective skills, therefore feedback does not resonate
  • Resistant or defensive learners

While the above barriers may be common concerns that educators have when approaching feedback, studies have proven that formative feedback trumps giving sole appraisal. Studies have shown that, while learners are more satisfied with recognition of their positive skill sets that are congruent with their own self-appraisal, learners demonstrate greater clinical improvement with constructive feedback. Thus, several theories have been proposed that involve a technique that include both positivity and constructive feedback.

Works Cited

Anderson, Peter A. "Giving Feedback on Clinical Skills: Are We Starving Our Young?" Journal of Graduate Medical Education, vol. 4, no. 2, 2012, pp. 154-158.

Brukner, Halina. "Giving effective feedback to medical students: a workshop for faculty and house staff." Medical Teacher, vol. 21, no. 2, 1999, pp. 161-165.

Cantillon, P., and J. Sargeant. "Giving feedback in clinical settings." BMJ, vol. 337, no. nov10 2, 2008, pp. a1961-a1961.

Ende, J. "Feedback in clinical medical education." JAMA: The Journal of the American Medical Association, vol. 250, no. 6, 1983, pp. 777-781.

Hesketh, E. A., and J. M. Laidlaw. "Developing the teaching instinct, 1: Feedback." Medical Teacher, vol. 24, no. 3, 2002, pp. 245-248.

Kritek, Patricia A. “Strategies for Effective Feedback.” Seminars for Educators, vol. 12, no. 4, 2015, pp 557-560. 

Ramani, Subha, and Sharon K. Krackov. “Twelve Tips for Giving Feedback Effectively in the Clinical Environment.” Medical Teacher, vol. 34, no. 10, 2012, pp. 787–791.

Richardson, BK. “Feedback.” Academic Emergency Medicine, vol. 11, no. 12, 2004, pp 1-5. 

Telio, Summer, et al. "The “Educational Alliance” as a Framework for Reconceptualizing Feedback in Medical Education." Academic Medicine, vol. 90, no. 5, 2015, pp. 609-614.

Van De Ridder, J. M., et al. "What is feedback in clinical education?" Medical Education, vol. 42, no. 2, 2008, pp. 189-197.

Weinstein, Debra F. "Feedback in Clinical Education." Academic Medicine, vol. 90, no. 5, 2015, pp. 559-561.