Giving Feedback


Dr. Frank Fulco, Associate Program Director and Assistant Professor of Internal Medicine in the School of Medicine at Virginia Commonwealth University discusses the importance of timely and constructive feedback for medical learners.


Why is feedback so difficult to give and receive?

As important as feedback is to the development of the learner, it is still difficult to find time amid busy clinical schedules to provide feedback or to request it from learners. However, reluctance to provide feedback may stem from other factors.  Giving feedback crosses social norms about commenting on others which can make the feedback provider uncomfortable.   However, if giving and receiving feedback becomes a common, everyday event, the process is normalized so it becomes an expected part of the daily routine.

How should faculty prepare for delivering feedback?

Feedback needs to be linked to learner objectives.  First, faculty should observe the learner demonstrate behaviors associated with the desired goals and objectives.  Then, take notes of these behaviors and communicate the specifics of them to the learner later.  Lastly, and most importantly, deliver feedback as close in time to the observation as possible.  Feedback a day later provides much less benefit to a learner who needs to know what needs to be corrected in the moment or what went well from the faculty perspective.

What if I don’t have time to directly observe the learner?

Direct observation is essential to provide credible feedback.  Not only does feedback need to be provided immediately, but the faculty providing the feedback needs multiple opportunities to observe throughout a rotation or clerkship experience. Second-hand feedback is often of limited value to a learner since indirect sources of feedback tend to skew performance. The language of feedback should be nouns and verbs to provide objectively worded feedback. Adjectives and adverbs tend to inflame, inflate, or diminish the value of what is said since they often reflect the biases and attitudes of the feedback provider and say less about the actual observed encounter.

How do I prepare my learners to receive feedback?

Set the environment, label the conversation as feedback, and request the learner’s permission to give feedback (“May I give you some feedback?”) and then solicit the learner’s reaction and thoughts after delivering feedback.  Remember that the competitive nature of medical education leads many learners to view self-disclosure as risky.  Learners may resist revealing their areas of confusion, fearing that doing so will be used against them.  Aim for an atmosphere of learner safety to build a strong relationship between feedback provider and feedback receiver. It’s far more likely that feedback will be “heard” if you do.

Why do so many learners say that they don’t receive feedback on their performance?

The conversation inherent in giving feedback is complex and composed of many choices, including the choice to be unaware of receiving feedback.  People sometimes discard data that disagrees with their self-perception. This may occur if the feedback is perceived as a personal judgment, sends inconsistent messages, is given in a manner that is embarrassing or humiliating in front of others, or does not address learning goals.

What’s the risk of not providing feedback to learners?

Research shows that when learners do not receive feedback on a regular basis, they generate their own self-validation, concurrent with a growing sense of clinical experience and mastery.  When trainees provide their own feedback in the absence of preceptor feedback, the importance of written examinations becomes inflated and clinical skills become secondary to memory skills to demonstrate ability.

How do I teach myself how to give feedback to learners?

Whether you are a new faculty member trying to establish yourself in an academic medicine career or a tenured medical professor well steeped in the theory and practice of academic medicine, fostering the skill of giving feedback is an ongoing need.  Why do we need models for how to give feedback?  Outside of personal experience, many medical educators have limited frameworks for giving constructive feedback.  Different models may resonate with different individuals, so having a repertoire to choose from can be useful in nurturing this complex skill.

Feedback

This essential part of the learning cycle is necessary to correct mistakes, change behavior, or continue good performance.  When you describe specific behavior around the knowledge, skills, and attitudes you want the learner to gain, you provide information about his or her current performance in a way that will guide future learning and performance.  Without this feedback, the learner may assume that he or she is performing adequately.

It Takes Two

As with any form of communication, feedback requires a ‘giver’ to provide information and a ‘receiver’ to take in that information.  These roles may oscillate during an interaction, but there is always a give and take between at least two parties.  By definition feedback will always be more about the giver than the receiver; a giver can only describe his or her perceptions based on personal experience.  It is important to remember that the receiver has a choice about what to do with the feedback.

Feedback Disconnect

Faculty often say that they give plenty of feedback during a rotation or course.  Yet, learners often note that they do not receive enough feedback.  This disconnect between faculty and learner perceptions can be remedied by labeling an interaction as “feedback” when you start and finish the discussion.  Open the discussion by asking, “May I give you some feedback?”  This labels the interaction and makes sure the receiver is ready to hear feedback.

Four Components of Feedback

Content, or what you say, should focus on specific and concrete behaviors.  By keeping the content centered on the issue, you avoid making it personal.  Include positive content about behaviors the receiver should continue and corrective content about behaviors that need to change or improve.  Always try to relate your content to the learning objectives, and limit corrective feedback to two or three items at a time.

Manner, or how you say it, will affect the receiver’s receptivity to and valuation of your feedback.  Avoid judgmental or emotional comments.  When either the giver or receiver is angry or frustrated, corrective feedback should be delayed if possible until it can be delivered in a constructive way.

Timing, or when you say it, should be as close to the class session or clinical scenario as possible, so ASAP.  However, negative or corrective feedback should be given as soon as reasonable, so ASAR.  Use your best judgement about when to give corrective feedback until you can assure that the discussion will focus on concrete behaviors instead of emotional reactions and that the receiver will be receptive.

Frequency, or how often you say it, is also important.  Learners crave feedback, so offer feedback as often as possible.  Even though instructors often feel like they give ample feedback, learners regularly report not getting enough.  Try leading with “May I give you some feedback?” to draw attention to the fact that you will be doing so.  When given often, the feedback process is normalized for the receiver.

Models for Delivering Feedback

Ask-Tell-Ask
This model for giving feedback begins by asking the receiver to reflect on and self-assess their performance.  The giver then tells what they observed, either validating or adding to the self-assessment, and provides concrete instruction for change.  The giver then asks the receiver to confirm understanding.  This question sequence may be, “How do you think you performed in that encounter?” followed by behavioral observations and suggested improvements to those behaviors, followed by “Do you understand or have questions about the feedback you just received?”

Feedback “Wrap” vs. Feedback “Sandwich”
Some faculty are in the habit of sandwiching a critique between two compliments. This leads the learner to hear the criticism but miss the compliments. Consider instead using a feedback “wrap” by weaving together possible improvements and positive feedback together.  Used effectively during a formal feedback meeting, the “wrap” allows the giver and receiver to collaboratively construct an improvement plan.

B.O.O.S.T.
This model summarizes the qualities of effective feedback as Balanced, Observed, Objective, Specific, Timely. Feedback should include growth opportunities and strengths, be based on direct observations, lack judgement statements, be supported by specific behavioral examples, and be discussed as close to the encounter as possible.

Stop, Start, Continue
This type of feedback outlines behavior that is not working (what to stop doing), how to improve that behavior (what to start doing), and what is working (what to continue doing). The flexibility and simplicity of this model is helpful; it can be used informally or formally, verbally or by email, peer-to-peer or faculty to learner.