The provision of effective feedback to medical learners is an important component in clinical teaching, yet literature suggests that clinical teachers often do not do this task well. 1, 2, 3, 5 In addition learners state they would like to receive more feedback: They recognize the need to receive feedback in order for progression of clinical skills to occur. Feedback is a formative process involving the provision and exploration of information to enhance learning and thereby improve performance. The focus is on observed behaviors or actions, not the individual, with the goal to reinforce those behaviors that are excellent and change those that need improvement.4 Feedback can be delivered using a variety of approaches: direct, the 'sandwich', Pendleton's approach, the ALOBA approach, SCOPME model, the Chicago model, the six step problem solving model, the five step micro-skills model of clinical teaching, or it can be a reflective conversation that involves degrees of self assessment.5,6 All methods have strengths and limitations. There are different types of feedback; it can be brief, formal or major.1,2 The technique or type of feedback used will depend on the level and ability of the learner, the comfort of the teacher, the clinical or teaching context and the nature of the situation requiring feedback. The process of ensuring effective feedback is delivered and leads to learning can be complex, and requires at least the steps below.
Establish a culture of feedback
Establishment of a culture where feedback is expected, accepted and used to improve performance is critical. It can be a difficult task, but once that culture is established, it paves the way for better interactions for both learners and teachers. Establishing such a culture means incorporating the how, what, why, when and where of feedback into the routine of a rotation or clinical assignment: It should be delivered at the end of each shift/day/week in a consistent manner, it should be specific and useful feedback on skills, knowledge or attitudes (the three domains of learning) that have been observed, it should be provided with the purpose of helping learners develop and improve, and it should be delivered in as private a place as possible.4 Set up the culture of feedback by ensuring it is talked about in any orientation for learners starting in, or returning to, a clinical environment, and by ensuring all teachers are also prepared and willing to provide feedback. One of the important components of the feedback process that is coming to the forefront is how the information in a feedback session is only one piece of the puzzle in change and progression for learners. The relationship and trust in the provider of that feedback is a critical element, and key to the learner accepting and following through on the changes that are needed.4,7 When that accepting, established culture of feedback is present, learners will feel more comfortable soliciting or seeking feedback and with receptive, engaged teachers, the interaction becomes more realistic and genuine. Reciprocal feedback should also be requested, as how can we foster a culture of feedback if as teachers we do not seek to improve our own skills?
Encourage and support self-reflection
Using reflection as a part of the feedback interaction can be very rewarding, particularly when the learner has reflected on an action or behavior, has incorporated this reflection into their own pre existing cognitive framework and then established a need for a change themselves. To start the reflective process, start the feedback conversation with open questions. "When you were performing the physical exam of the abdomen, what did you notice about the child's reaction?" "What things could you do differently next time you examine a child that age?" or "Is there anything you feel went particularly well today?" Those simple questions require the learner to think about their performance. The reflective conversation should revolve around skills, knowledge and attitudes that have occurred as an observed action or behavior, involve a clear exploration and explanation of what the preferred behavior is, a discussion of the difference between the two and finally, a solution on how to eliminate that difference in the next appropriate clinical opportunity.2,8
Establish a clear plan with action items
Once feedback is provided, it is important to follow up on what was discussed. The action items are the areas that must improve, those areas that are crucial to progression and change in the learner.4 Setting these action items will reinforce learning, and following through on the action items ensures that a practice opportunity to improve is taken. The goal of providing effective feedback is to ensure a learner progresses and that they make improvements to how they practice. This can best be accomplished if learners are aided by a supportive teacher to understand exactly what they do well, exactly what they need to improve on and, how to do it. Providing feedback effectively is one arena in which to enhance learners' long-term success as caring competent physicians.
- Gigante J, Dell M, Sharkey A (2011). Getting beyond "Good Job": How to Give Effective Feedback 127(2): 205-207
- Branch W and Paranjape A (2002). Feedback and Reflection: Teaching Methods for Clinical Settings. Academic Medicine 77 (12): 1185-1188
- Hewson MG, Little ML. (1998). Giving feedback in medical education: Verification of recommended techniques. J Gen Intern Med 113:111-118
- Ramani S, Krackov S. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher 34:787-791.
- Cantillon P and Sargeant J (2008). Giving feedback in clinical settings. BMJ 337:a1961.
- Chowdhury R, Kalu G (2004) Learning to give feedback in medical education. The Obs and Gyne 6: 243-247
- Eva K and Regehr G (2013). Effective feedback for maintenance of competence: from data delivery to trusting dialogues. CMAJ April 2; 185:463-464
- Mann K, Gordon J, Macleod A. (2007) Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Edic Theory Pract 2007;14:595-621.
Written for October 2015 by
Barbara Blackie, MD
Co Associate Chief of Education
Senior Attending Emergency Physician for Pediatric Emergency Services
Sidra Medical & Research Center