The Feedback Loop

November’s article explores supervisors’ perceptions of feedback-seeking behavior. Feedback-seeking behaviors can influence the way supervisors respond, framing the feedback experience.

Highlights:

• Seeking feedback is an expected competency for medical trainees. However, requiring feedback seeking behaviors may make this activity yet another thing to do rather than a genuine exchange.
• Individuals may be more inclined to seek feedback when they perceive it will make a good impression, and reluctant to do so when they feel the opposite.
• When clinical supervisors perceive feedback seeking behavior as a desire to impress rather than improve, it shifts the way in which they provide feedback.
• Supervisors perceived four distinct motivations behind feedback seeking behavior: affirmation, improvement, requirement, and hidden.
• Hidden motivations for seeking feedback included behaviors such as impression management or needing to request a letter of recommendation.
• Participants reported five factors that influenced their response to feedback seeking behaviors: initial request, timing, preexisting relationship, learner characteristics, and learner reaction to feedback.

Ginsburg, Shiphra, et al. ""I Think Many of Them Want to Appear to Have a Growth Mindset": Exploring Supervisors' Perceptions of Feedback-Seeking Behavior." Academic Medicine 99.11 (2024): 1247-1253. Journals@Ovid Full Text. Web. 12 November. 2024.

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October’s article explores challenges with involving patients in the provision of workplace-based feedback for clinical learners.

Highlights:

• Patients are increasingly involved in evaluation of care and quality improvement processes.
• Involving patients in the feedback process shifts them from passive recipients of care to active participants in the care process.
• Linking patient feedback to workplace learning is a challenging concept in both theory and practice.
• Study participants identified four improvement goals for patient-based feedback: 1) Improving treatment relationships, 2) healthcare provider performance, 3) team-level care processes, and 4) organizational-level care processes.
• Patients reported preferring to provide positive feedback in person and negative feedback in writing to avoid confrontation.
• Providers reported that direct feedback was important to performance improvement when it was discussed using concrete examples.
• Providers reported not routinely inviting patient feedback, which patients reported not being willing to provide it spontaneously.
• Many patients reported wanting to be seen as a part of the health care team where their feedback was valued and used for improvements.
• Despite valuing the role of patient feedback, providers and patients reported not knowing how to engage in these conversations.

Sehlbach C, Bosveld MH, Romme S, Nijhuis MA, Govaerts MJB, Smeenk FWJM. Challenges in engaging patients in feedback conversations for health care professionals' workplace learning. Med Educ. 2024; 58(8): 970-979. doi:10.1111/medu.15313

September’s article explores cognitive and affective influences on the provision of written feedback.

Highlights:

• Feedback is a two-way communication process that ideally triggers self-assessment and performance improvement.
• The nature of written feedback inhibits student response and, therefore, creates a one-way form of communication that is more prone to misinterpretation.
• High-quality written feedback stimulates student reflection.
• Faculty reportedly see providing written feedback as demanding and exhausting, expressing frustration in students’ inability to improve based on the feedback.
• Providing written feedback is both a cognitive and emotional process.
• Four main components to providing written feedback were identified: teachers during the observation and interpretation process, students’ tasks and performance, feedback impact, and institutional culture and policies.
• Providing written feedback involves cognitive burden due to the need to construct effective sentences, along with emotional burden related to the importance of providing effective feedback.
• Differences between faculty members’ feedback can cause stress and confusion. This may be mitigated by clear expectations for faculty and appropriate faculty development.

Soemantri D, Pinasthika A, Greviana N. Is There Feedback Fatigue? Medical Teachers’ Views on Cognitive and Affective Factors in Providing Written Feedback. Education in Medicine Journal. 2024;16(2):101-117. doi:10.21315/eimj2024.16.2.7

August’s article explores the roles of immediate and delayed feedback in test performance.

Highlights:

• Formative practice testing, also known as test-enhanced learning, is a powerful learning strategy.
• Provision of feedback during formative testing can further augment learning.
• Feedback during formative testing may enhance learning, but the timing of effective feedback is in question.
• More elaborate forms of feedback have been shown to provide greater benefit to medical students than binary, right-or-wrong feedback.
• Evidence indicates that immediate feedback may increase item correction whereas “delayed” feedback may increase retention and transfer.
• Study findings suggest there is not a significant difference in whether feedback is delivered immediately or after a delay during formative testing.
• Evidence suggests that feedback needs to be performed in a timely manner, where minor delays don’t have a significant impact, but lengthy delays may hinder the efficacy of the feedback process.

Ryan AT, Judd T, Wilson C, et al. Timing's not everything: Immediate and delayed feedback are equally beneficial for performance in formative multiple-choice testing. Med Educ. 2024; 58(7): 838-847. doi:10.1111/medu.15287

May’s article explores feedback and coaching in medical education.

Highlights:

• Feedback and coaching accelerate clinical learning.
• The definition of feedback has changed from one of feeding information back into a learner to compare their performance to a standard to one that reflects the dynamic social nature of the activity, one in which understanding is co-created to support learner growth.
• Feedback is a conversation, not a transaction.
• Feedback is a tool; coaching is a philosophy. Coaching uses feedback along with direct observation, goal setting, and reflection to foster learner development.
• Coaching focuses on assessment for learning rather more summative assessment of learning.
• Feedback is most likely to be effective if given in a constructive and actionable manner.
• Students and residents are less receptive to feedback when it is provided as a summative assessment of their performance. They are more receptive when the feedback is presented as a low-stakes learning opportunity.

Atkinson, A., Watling, C.J. & Brand, P.L.P. Feedback and coaching. Eur J Pediatr 181, 441–446 (2022).

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April’s article provides a practice guide to giving and receiving feedback in the workplace.

Highlights:

• Professional success and growth is influenced by how well a person can elicit and respond to feedback.
• It is important to demonstrate genuine interest in obtaining feedback to help providers overcome uncertainties about sharing their perceptions.
• Embrace a growth mindset for receiving feedback, viewing your abilities as traits that can be developed over time rather than fixed assets.
• Set aside an appropriate amount of time for open, one-on-one feedback to ensure you can have an adequate discussion.
• Negative reactions to feedback are the result of three types of triggers: truth triggers, relationship triggers, and identity triggers.
• Truth triggers are the result of the content of the feedback itself.
• Relationship triggers stem from the person delivering the feedback.
• Identity triggers focus on threats to one’s identity.
• Responding to critical feedback involves creation of an action plan to address the issues that were raised.

Quach, David, et al. “A Practical Guide to Feedback in the Workplace: Interpreting and Acting on Feedback from Learners and Direct Reports.” American Journal of Health-System Pharmacy, vol. 77, no. 19, Oct. 2020, pp. 1552–55. EBSCOhost.

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March’s article examines the R2C2 model for feedback and coaching. The study explored application of the model in fostering in-the-moment feedback conversations between preceptors and learners.

Highlights:

• The R2C2 (relationship, reaction, content, coaching) model is an evidence-based, theory-informed model that targets performance improvement and behavior change.
• The four iterative phases of the model allow for building a relationship, exploring reactions, confirming content, and co-creating an action plan.
• R2C2 was originally designed for practicing physicians but has been adapted and applied across the continuum of medical education, from medical students to residents to practicing physicians.
• Adapting the model for in-the-moment (ITM) feedback included having learners self-reflect on the clinical experience rather than rely on written documentation and focusing on a single action plan rather than a few at a time.
• Duration of ITM feedback ranged from 4 to 22 minutes, with a median of 12 minutes.
• Feedback conversations occurred during clinical time, gaps in schedules, following a clinical session, or early the following day.
• Many of the dyads struggled with developing a clear action plan that included follow-up with that or another preceptor.
• The R2C2 model was valued by participants and found to be applicable to ITM feedback.
• Preceptors appreciated the structured approach of the model but were variable in their application of the steps, particularly coaching and co-creating action plans.
• Coaching is a complex and bidirectional process, one which requires learning, unlearning, and facilitative communication skills. These skills are not intuitive, requiring coaching for the preceptors themselves.

Lockyer, Jocelyn, et al. "Application of the R2C2 Model to In-the-Moment Feedback and Coaching." Academic Medicine 98.9 (2023): 1062-1068. Journals@Ovid Full Text. Web. 06 March. 2024.

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This month's article examines feedback provided to medical students on their note-writing skills. In this scoping review, the authors explored the literature to understand methods used to provide feedback on note-writing skills and the influences of technology.

Highlights:

• The quality of note-writing is increasingly important in the modern health care system.
• Suspension of the USMLE Step 2 Clinical Skills exam shifted responsibility for assessing and providing feedback on note-writing skills back to academic institutions.
• Note-writing involves skills in synthesis of information, clinical reasoning, organization, and generation of a differential diagnosis.
• Note-writing is a universal activity that is relatively easily used to provide feedback both individually and in group formats.
• Six themes were identified from the literature:
  • Learners found feedback helpful
  • Rubrics and checklists were the most common feedback methods
  • Most of the literature focuses on pre-clinical, simulated education and not real clinical settings
  • Training on providing and receiving feedback were helpful for faculty and students
  • Sequential, iterative feedback was most helpful but is more time and resource intensive
  • Use of technology and validated tools eases communication and improves organization

Hansen, Allison1; Klute, Ryan M. MS2; Yadav, Manajyoti MD3; Bansal, Saurabh MD4; Bond, William F. MD5. How Do Learners Receive Feedback on Note-Writing? A Scoping Review. Academic Medicine ():10.1097/ACM.0000000000005653, February 2, 2024. | DOI: 10.1097/ACM.0000000000005653

This month’s feedback article explores how learners make meaning of feedback in specialty-specific cultures.

Highlights:

• Feedback in the surgical environment was found to be more reliant on patient outcomes and quality of care, whereas feedback in the intensive care environment was more reliant on tacit emotional support.
• Differences in specialty-specific cultures influenced how trainees sought feedback, made meaning of their day-to-day performance, and collated information into an understanding of overall progress.
• Learners engage in two kinds of meaning making: understanding immediate performance in the context of patient care and patching together an overall understanding of their overall performance from a variety of sources.
• Feedback conversations often center on providing advice rather than helping a learner understand their performance.
• Productive feedback involves learners making meaning and acting on knowledge about the quality of their performance.

Bearman M, Ajjawi R, Castanelli D, et al.. Meaning making about performance. Medical Education. 2023; 57 (11): 1010-1019. doi: 10.1111/medu.15118.

This month’s feedback article explores provision of feedback in the clinical setting, particularly in the Emergency Department setting. It addresses the challenges of providing feedback in a fast-paced, high acuity patient care setting where feedback is often relegated to positive comments or overlooked completely.

Highlights:

• Feedback that is poorly received by the learner is less likely to be applied to future performance.
• Feedback should be timely, specific, well-informed, and actionable.
• The four components of providing feedback in this setting include establishing expectations, setting the stage, providing specific feedback based on direct observation, and establishing respect and trust.
• There are three triggers that influence reception of feedback by the learner: truth, relationships, and identity.
• The truth trigger inhibits the learner’s ability to accept the feedback as correct. Learners can work through this trigger by asking questions to understand the context of the feedback.
• The relationship trigger influences learner receptivity through their perception of the feedback giver’s credibility. One strategy to addressing this trigger is to establish feedback goals at the beginning of the working relationship.
• The identity trigger is a defense mechanism that activates when the learner feels they are under attack. Nurturing a growth mindset in learners whereby they can accept their mistakes and view them as an opportunity for learning is important.
• Creating a culture of feedback is important to sustain effective feedback practices. Providers should be given time to conduct direct observations and training on providing feedback.

Catherine Buckley MD, Sreeja Natesan MD, Adam Breslin MD and Michael Gottlieb MD. Finessing Feedback: Recommendations for Effective Feedback in the Emergency Department. Annals of Emergency Medicine, 2020-03-01, Volume 75, Issue 3, Pages 445-451

This month’s feedback article explores the theoretical roots of feedback and debriefing in medical education. The authors propose merging the two terms into a new category: learning conversations.

Highlights:

• Feedback and debriefing are core facilitators in promoting constructive reflection in experiential learning environments.
• Feedback and debriefing often diverge in how they are defined as well as how, when, and where they are used.
• Conceptualizing feedback in medical education as merely the sharing of information fails to consider learners’ will and emotions.
• Feedback should target the task and not the person.
• Debriefing is described as a post-event learning conversation.
• Debriefing in medical education is often reserved for simulation experiences.
• Feedback and debriefing are dependent on cognitive and social influences.

Tavares, Walter, Eppich, Walter, MD, PhD, et al. Learning Conversations: An Analysis of the Theoretical Roots and Their Manifestations of Feedback and Debriefing in Medical Education. Acad Med. 2020;95(7):1020-1025. doi:10.1097/ACM.0000000000002932.

This month’s feedback article explores medical students’ experiences with the order in which feedback is given and its impact on how students receive it.

Highlights:

• Positive-message-first models of feedback are thought by some experts to make students more receptive to receive and providers more willing to give negative feedback. Critics of this approach assert that it makes recipients a passive part of the feedback process.
• Optimal feedback order is likely dependent on the learner and situation in which the feedback is given and received.
• Students’ view of feedback evolves over time, moving from passive to more active involvement in the process.
• Student preference regarding order of feedback may be related to their adoption of a fixed or growth mindset.

Katharine A. Robb, Marcy E. Rosenbaum, Lauren Peters, Susan Lenoch, Donna Lancianese, Jane L. Miller, Feedback conversations: First things first?, Patient Education and Counseling, Volume 115, October 2023, 107849, ISSN 0738-3991, https://doi.org/10.1016/j.pec.2023.107849.

This month’s feedback article explores feedback language in relation to Dr. Carol Dweck’s work with fixed and growth mindsets. Student self-efficacy, or self-perception of learning ability, has been linked with higher academic success. The language used when providing feedback may influence learners’ self-efficacy and promote a growth mindset.

• Praising learners for being “smart” can send a message that appearing intelligent is the goal, inadvertently encouraging learners to focus on appearance of intelligence rather than the process of learning itself.
• Feedback should focus less on fixed attributes, such as intelligence, and more on process-oriented efforts that encourage hard work and continued development.
• Promoting attributes such as seeking challenges, overcoming hardship, or reinforcing problem solving and critical thinking attributes may help learners adopt a growth mindset toward their learning and development.
• Using the term “yet” may be a powerful communication tool, indicating that a skill is in development and can be achieved.

Ricotta DN, Huang GC, Hale AJ, Freed JA, Smith CC. Mindset theory in medical education. Clinical Teacher. 2019;16(2):159-161. doi:10.1111/tct.12765

While peer feedback is recognized as a powerful learning tool, many are inexperienced in providing meaningful feedback. This month’s article explores the kind of experiences that improve peer feedback quality.

Highlights:

• Low-performing students demonstrated more growth than their high-performing counterparts in helpfulness from providing feedback.
• Peer feedback requires development through extensive experience.
• Students can increase their knowledge and skills through giving and receiving feedback.
• Research suggests that feedback from peers is as effective as teacher assessments.
• Opportunities to practice providing feedback improved the quality of feedback over time.
• Providing feedback is more consistently associated with learning outcomes than is receiving feedback.

Zong, Zheng, et al. “Learning to Improve the Quality Peer Feedback through Experience with Peer Feedback.” Assessment & Evaluation in Higher Education, vol. 46, no. 6, Sept. 2021, pp. 973–92.

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Giving and receiving feedback can be difficult. This month’s article highlights common pitfalls in receiving feedback and how to overcome them.

Highlights:

• Passively waiting for feedback results in little to no feedback being given, and what is received often being unspecified. Reflecting on your own performance and asking for targeted feedback is advised.
• Using feedback opportunities for validation rather than improvement degrades the process. Bear in mind that feedback is meant to help, not harm.
• Limiting the people from which you seek and accept feedback only provides a partial view of your performance. Seek feedback from peers and colleagues, not just superiors.
• Reacting defensively reduces the effectiveness of the feedback provided. Receive feedback as a reflection of your performance and not a personal judgement against you.
• Superficial processing and response to feedback fail to provide deeper learning experiences. Analyze feedback thoroughly before accepting or rejecting it.
• Failure to act on feedback negates the process. Feedback is meant to be processed and acted on to improve future performance. Think about how and when you can apply the feedback.

Tielemans, Claudia J.M. MSc1; Eijkelboom, Charlotte M.C.L. MSc2; Lesterhuis, Marije PhD3; de Vreugd, Lars B. MSc4; Pennings, Helena J.M. PhD5; de Kleijn, Renske A.M. PhD6. Receiving Feedback Is Not Easy! Six Common Pitfalls. Academic Medicine ():10.1097/ACM.0000000000005099, November 15, 2022. | DOI: 10.1097/ACM.0000000000005099

The ARCH Model for Feedback addresses issues with the historical “feedback sandwich” model. Namely, ARCH includes self-assessment, goal setting, and development of an action plan. The model includes the following components:

A = Allow/Ask for self-assessment
R = Reinforce what is being done well (attitudes, skills, and knowledge)
C = Confirm what needs Correction or improvement
H = Help the learner with an action plan for improvement and coach as needed

Highlights:

• Learners must feel safe to do an honest self-assessment and share it with the instructor.
• Instructors should reinforce what is being done well prior to confirming what areas need improvement.
• Start the confirmation step by echoing the learner’s self-identified areas, confirming that you have heard their concerns.
• Development of the improvement plan should include both instructor and learner.

S. Dennis Baker, PhD; Gregory Turner, EdD; Suzanne C. Bush, MD. (2015). ARCH: A Guidance Model for Providing Effective Feedback to Learners

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This month’s article highlights six common pitfalls in receiving feedback.

Highlights:

• Passively waiting for feedback results in receiving little to no specific feedback to improve performance. Ask focused questions for feedback related to learning and performance goals.
• Asking for feedback for the wrong reasons results in receiving no points of improvement. Highlight areas in which you struggle when asking for specific feedback.
• Only seeking feedback from superiors results in a narrow perspective of actual performance. Seek feedback from a variety of colleagues to inform performance improvement.
• Reacting defensively to feedback hinders analysis and use of the feedback provided. Express appreciation for the feedback while acknowledging your feelings.
• Failure to thoroughly analyze the feedback results in superficial learning. Seek clarification on points of confusion to foster deeper reflection.
• Failure to act on feedback does not improve performance. Ask for follow-up observations to assess growth.

Tielemans, Claudia J.M. MSc1; Eijkelboom, Charlotte M.C.L. MSc2; Lesterhuis, Marije PhD3; de Vreugd, Lars B. MSc4; Pennings, Helena J.M. PhD5; de Kleijn, Renske A.M. PhD6. Receiving Feedback Is Not Easy! Six Common Pitfalls. Academic Medicine ():10.1097/ACM.0000000000005099, November 15, 2022. | DOI: 10.1097/ACM.0000000000005099

This month’s article explores using peer feedback to help address challenges with feedback in the clinical setting. The experiences of 12 pediatric trainees were studied using a phenomenological approach.

Highlights:

• Trainees report clinical feedback as infrequent and/or ineffective.
• Feedback is influenced by interpersonal dynamics, with trainees judging various factors when determining whether to apply it.
• Peer feedback may be powerful and more accessible.
• Peer feedback may promote critical reflection, evaluative judgement, and recognition of standards.
• Peer feedback is not emphasized in the same manner as trainer-trainee feedback.
• Trainees are not educated on giving and receiving feedback, influencing their ability to recognize and respond to feedback.

John Joyce, Peter Cantillon & Rosemary Geoghegan (2022) Peer feedback in graduate training: A phenomenological investigation of possibilities, Medical Teacher, 44:12, 1362-1367, DOI: 10.1080/0142159X.2022.2094229

This month’s article explores feedback receptivity in health professions learners. While much of the feedback literature focuses on provision of feedback, relatively little addresses the reception of feedback information and learner’s response.

Highlights:

• Feedback receptivity is described using four domains: utility, accountability, social awareness, and feedback self-efficacy.
• Learner characteristics in receiving feedback include readiness (ability to hear and respond to feedback without emotion), willingness (valuing the feedback), and ability (processing the feedback effectively).
• Feedback orientation includes six domains: general affect, propensity to seek feedback, inclination to process feedback constructively, awareness of others’ perceptions, belief in the value of feedback, and a sense of responsibility to act on feedback.
• Medical learners’ feedback orientation was found to be relatively high and stable.

Lynnea M. Mills, Patricia S. O’Sullivan, Olle ten Cate & Christy Boscardin (2022) Investigating feedback orientation in medical learners, Medical Teacher, DOI: 10.1080/0142159X.2022.2138741

This month’s article focuses on medical students’ perceptions of resident feedback. The study found that supportive resident relationships fostered receptivity to feedback and even played a role in professional identity formation. Unsupportive relationships resulted in hesitancy to seek and apply feedback.

Highlights:

• Social constructivist perspectives on feedback focus on the interdependent relationship between instructor and learner.
• Learners’ perception of the quality of the relationship is key to the relationship’s influence on learning.
• The near-peer nature of resident-student relationships gives them a unique role in medical education and the feedback process.
• When residents build interpersonal relationships with students, the students become more receptive to encouraging and constructive feedback.
• When relationships were built, students’ response to feedback influenced their clinical learning and work along with their vision of themselves as future practitioners.
• When students are welcomed to the team by residents, they report feeling more respected and valued.
• Relationship building requires participation from resident and student, where students need to invest in the relationship as well for it to become beneficial.
• In the context of a positive relationship, students were more likely to value constructive feedback as being uniquely tailored to them.

Wong, SN, Luo, C(J), MacDonald, G, Hatala, R. A qualitative study of medical students' perceptions of resident feedback. Med Educ. 2022; 56( 10): 994- 1001. doi:10.1111/medu.14847

This month’s article focuses on the complete feedback loop, which the author asserts begins the first time the instructor and learner meet.

Highlights:

• Creating a positive learning environment where exchange of information is welcome sets the stage for a strong feedback relationship.
• Learning goals should be communicated as specific behaviors, and learners should establish their own goals and communicate them to instructors.
• Beginning the feedback exchange with learner self-reflection can open their receptivity to corrective feedback.
• Developing an action plan closes the feedback loop and encourages performance improvement.

Subha Ramani (2016) Reflections on feedback: Closing the loop, Medical Teacher, 38:2, 206-207, DOI: 10.3109/0142159X.2015.1044950

This month’s article addresses the presence of emotions in the feedback process. The authors assert that investigating emotions in feedback could help address its presence in productive ways.

Highlights:

• Some feedback models seek to balance positive and negative emotions to prevent defensiveness in the process.
• Four components of feedback literacy are: appreciating the feedback, making judgments, managing emotions, and taking action.
• Emotion as physiology: views emotions as biological processes to be managed. This approach treats emotion as damaging to the feedback process.
• Emotion as skill: views emotions as cognitive and malleable. This approach treats emotion as something that needs to be processed before acting.
• Emotion as reflexive practice: views emotions as social and interpersonal. This approach treats emotion as an influence on behavior.
• Emotion as socio-cultural mediator: views emotions as political. This approach treats emotions as mediators in the way a trainee becomes part of a community of practice.

Ajjawi, R, Olson, RE, McNaughton, N. Emotion as reflexive practice: A new discourse for feedback practice and research. Med Educ. 2022; 56(5): 480- 488. doi:10.1111/medu.14700

This month’s article focuses on feedback behaviors of faculty who use the mini-CEX, or mini-clinical evaluation exercise, to assess student performance and provide feedback.

Highlights:

• Student performance in the clinical setting is typically assessed following direct observation of a skill or task.
• Tools such as the mini-CEX allowed supervisors to provide meaningful feedback.
• Personal educational viewpoints influence the assessment and feedback process.
• As individuals vary in the ways they collect and process observation data on students, feedback giving behaviors are also variable.
• Concern with patient safety during consultations results in more frequent observations and higher quality feedback.
• Written feedback often lacks information students can use to improve their performance.
• Written feedback is more taxing on supervisors, requiring more time and effort to compile and construct.
• Long-term supervisor/student relationships improve the quality of feedback in terms of credibility and constructiveness.

Harold G. J. Bok, Debbie A. D. C. Jaarsma, Annemarie Spruijt, Peter Van Beukelen, Cees P. M. Van Der Vleuten & Pim W. Teunissen (2016) Feedback-giving behaviour in performance evaluations during clinical clerkships, Medical Teacher, 38:1, 88-95, DOI: 10.3109/0142159X.2015.1017448

Feedback drives the learning process towards achieving goals. There are a variety of feedback types in medical education, each serving a specific purpose in helping the teacher and learner work together.

Highlights:

• Intrinsic, or short, feedback is driven by students.
• Extrinsic, or long, feedback is driven by teachers.
• The goal of providing feedback is to help the learner reach their full potential.
• Competency-based medical education, or CBME, is a student-centered process.
• Many types of feedback treat the learner as a passive recipient of information.
• Intrinsic feedback requires a learner to have keen observation skills, self-awareness, self-analysis, and motivation to improve.
• Extrinsic feedback helps learners calibrate their actual performance to their desired performance.
• High achieving students rely more on intrinsic than extrinsic feedback.
• In CBME, the goal of teachers should be to move learners from dependence on extrinsic feedback to use of intrinsic feedback.

Velou MS, Ahila E. Types of feedback in medical education - A new hypothesis in alignment with competency-based medical education. International Archives of Integrated Medicine. 2020;7(8):86-90.

Feedback is a fundamental component of teaching and learning meant to reinforce strengths and improve performance. Faculty development programs often work to develop feedback skills. This study sought to identify faculty characteristics associated with providing high-quality feedback.

Highlights:

• Providing high-quality feedback is a complex and fundamental teaching skill set.
• Learner-centeredness is associated with high-quality feedback. Understanding individual learner needs is an important first step in developing a teaching and learning relationship.
• Faculty who elicit and process feedback on their own performance were found to provide higher quality feedback to their learners.

Menachery, E.P., Knight, A.M., Kolodner, K. et al. Physician characteristics associated with proficiency in feedback skills. J GEN INTERN MED 21, 440–446 (2006).

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Outcomes-based medical education focuses on development of the competencies expected of healthcare professionals. In her commentary, Sharon Krackov discusses the role of feedback in this process.

Highlights:

• Deliberate practice is a necessary component of outcomes-based education, with feedback providing essential information for growth and development.
• Feedback helps a learner achieve and maintain expertise.
• Feedback in conjunction with formative and summative assessment is the foundation of an iterative curriculum process.
• Feedback should be a two-way communication tool that engages both learner and teacher.
• The clinical learning environment may present a barrier to effective two-way feedback.
• Feedback should be a regular part of the educational experience.

Sharon K. Krackov (2011) Expanding the horizon for feedback, Medical Teacher, 33:11, 873-874, DOI: 10.3109/0142159X.2011.617797

Feedback is often viewed as a faculty-driven process, with the learner taking a relatively passive role. This month’s article presents a student-centered feedback model that focuses on their requests for and responses to feedback.

Highlights:

• Faculty-driven feedback may be viewed as something done to students rather than a healthy exchange of information between mature people.
• Students should take more responsibility for seeking and responding to feedback.
• Students should actively identify their learning needs and ways to meet them, which may or may not require frequent feedback from a supervisor.
• Students need to develop a receptiveness to feedback, including placing value on the information they receive as vital to their development.
• In this model, the quality of feedback is shaped by the student’s ability to seek clarification, evaluate the feedback against their own views, and seeking other opinions that differ or corroborate.

Rudland, J., Wilkinson, T., Wearn, A., Nicol, P., Tunny, T., Owen, C. and O’Keefe, M. (2013), A student-centered feedback model for educators. The Clinical Teacher, 10: 99-102.

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Feedback is delivery of data collected from direct observation experiences. Effective provision of feedback takes the giver, receiver, and environment into consideration. Each factor can enhance or hinder the feedback process.

Highlights:

• All feedback should focus on a specific behavior and include confirmation of understanding and an action plan for improvement.
• Feedback is formative and should be kept separate from evaluation tasks.
• Feedback should be a bidirectional conversation between the giver and receiver.
• Feedback conversations should be labeled as such, priming the giver and receiver to focus on the formative nature of the conversation.
• There are numerous methods for providing feedback, each with their own advantages and disadvantages.
• When feedback is predominantly positive, be sure to give the receiver at least one area of improvement to work on so they continue to improve.
• Receivers should be an active part of the feedback process, routinely soliciting feedback and avoiding defensive behaviors.

Jug R, Jiang X “’Sara”’, Bean SM. Giving and Receiving Effective Feedback: A Review Article and How-To Guide. Archives of Pathology & Laboratory Medicine. 2019;143(2):244-250. doi:10.5858/arpa.2018-0058-RA

Direct workplace observations provide a rich source for feedback in health sciences education. Feedback is influenced by relationships, shaping perception and interactions in ways that can promote and inhibit effective communication. This is especially true when interacting with different health professions, where power differentials may influence provision of and receptivity to performance feedback.

Highlights:

• Multisource, or 360-degree, feedback is a common tool used in health education to determine competence in the workplace.
• Data suggests that trainees find feedback more useful when coming from physicians than other health professionals.
• Health professional feedback to trainees differs depending on the nature of the interpersonal relationship present, such as teacher-learner or peer-peer.
• Workplace feedback can be both directive and facilitative. Directive feedback seeks to inform the trainee of what needs correction. Facilitative feedback focuses on professional growth and development of core competencies.
• Role clarity is important in the feedback process, as understanding specific skills and expertise of various team members factors into judging whether feedback is credible.
• Education programs should implement strategies to help mitigate power imbalances so feedback can achieve desired outcomes.

Miles, A, Ginsburg, S, Sibbald, M, Tavares, W, Watling, C, Stroud, L. Feedback from health professionals in postgraduate medical education: Influence of interprofessional relationship, identity and power. Med Educ. 2021; 55: 518– 529.

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Feedback is an important component to trainees developing self-regulated learning skills. In competency-based medical education (CBME), trainees are assessed through narrative and numerical ratings obtained from direct observation of skills. CBME relies on the relationships between feedback providers and receivers to foster long-term development.

Highlights:

• Self-regulated learning involves cycles of establishing learner-endorsed goals, facilitated performance monitoring, and revision of goals based on feedback.
• The study sought to determine whether narrative and numerical ratings were associated with one another, and whether they were consistent between residents (self) and faculty (observer).
• Little association was found between narrative comments and numerical ratings from faculty.
• Reasons for incongruence between narrative and numerical feedback include hedging, where negative feedback is softened, providing exaggerated positive feedback to boost confidence, and focusing on positive feedback to create a safe learning environment.

Egan R, Chaplin T, Szulewski A, et al. A case for feedback and monitoring assessment in competency‐based medical education. Journal of Evaluation in Clinical Practice. 2020;26(4):1105-1113. doi:10.1111/jep.13338

Receiving and reflecting on feedback is an important aspect of continuous professional development (CPD). While it is common to review multisource feedback one-on-one with a trusted advisor, new approaches involve reviewing feedback in a peer setting with a trained facilitator. Sharing feedback with others was found to make feedback more meaningful, deepen collegial relationships, and create a sense of urgency for improvement.

Highlights:

• Multisource feedback does not always result in performance change; multiple studies suggest that facilitation of reflection is required to initiate actual change.
• Facilitated reflection promotes deeper understanding of feedback and can be accomplished in one-on-one or group settings.
• Disclosing feedback information in a group setting can be unfamiliar and uncomfortable at first but may develop richer interpersonal relationships over time.
• Group discussion surrounding feedback may make individuals more open to reflection and subsequent action.
• Group development of performance improvement goals help to create a sense of urgency to change while allowing participants the opportunity to discuss potential barriers.

Bindels, Elisa, et al. "Sharing Reflections on Multisource Feedback in a Peer Group Setting". Academic Medicine, vol. Publish Ahead of Print, May 4, 2021, doi: 10.1097/ACM.0000000000004142.

Properly facilitated feedback can improve outcomes and foster analytical learning in trainees. Feedback skills can be learned and are an important part of an educator’s toolkit. This month’s article features two primary methods of providing feedback, Pendleton’s rules and ALOBA.

Highlights:

• Having been on the receiving end of harsh feedback during training, many instructors are hesitant to provide corrective feedback themselves.
• Effective feedback involves making trainees aware of their actions and subsequent consequences.
• Feedback is non-evaluative, objective appraisal of performance.
• Feedback should be specific, describing behavior that the trainee can change to improve their performance.
• Having the trainee self-assess can bring up points the instructor wishes to discuss without being threatening to the trainee.
• Feedback should be based on the trainee’s learning goals, which are established at the start of the teaching/learning relationship and refined over time.
• With the Pendleton’s rules approach, positives are outlined first to give trainees greater confidence and develop better rapport between the feedback provider and receiver.
• In the agenda-led, outcome-based analysis, or ALOBA, approach to feedback, the learner identifies the agenda and what they want help with to initiate the discussion.

Learning to give feedback in medical education (PDF)

A better understanding of how we learn has led to greater appreciation of the importance of feedback in the process. Quality feedback must have a strong basis in observation and evaluation of skills which result in discussion of what is necessary to achieve the next level of performance. While evaluation of skills is at the core of providing feedback, it is the discussion of the evaluation and offering of advice and guidance that turns assessment into feedback.

Highlights:

• Observation of performance: direct observation of the learner’s knowledge, skills, and attitudes is fundamental to begin the feedback process. Observation should be conducted with a critical eye, a skill that requires continuous attention and development.
• Evaluation of performance: the learner’s level of performance must be evaluated and used to guide and facilitate development to the next level.
• Guidance to achieve the next level of performance: the next level of performance should be described to the learner and related to their current performance level. This discussion should include an explanation of the importance and relevance of achieving the next level of performance.
• Facilitation of performance improvement: facilitating improvement involves the provision of educational resources, learning activities, timelines, and other activities that support the learner in achieving the desired outcomes.

A common problem with feedback is that it often gets skipped in the scheme of educational activities. Feedback also suffers from brevity and lack of details, such as simply stating “good job,” or from being delayed and thus removed from the learning activity and related performance. Providing direct observation with timely and meaningful feedback is thus an important skill to develop as an educator.

Feedback in Medical Education

Learners often report that the feedback they receive is infrequent and/or ineffective. Ramani argues the feedback exchange begins long before the feedback conversation occurs, being initiated upon the learner and instructor first meeting. The establishment of a positive, trusting working relationship is the first step to developing an effective feedback environment.

Highlights:

• Begin the teaching relationship and feedback process by establishing learning goals. Communicate those goals clearly.
• Encourage learners to self-reflect as part of the feedback process.
• Work with your learners to develop improvement plans so they are empowered to act on feedback.
• Focus the encounter on three questions: Where is the learner? Where does the learner need to be? How do they get there?

Ramani S. Reflections on feedback: Closing the loop. Medical Teacher. 2016;38(2):206-207. doi:10.3109/0142159X.2015.1044950

Feedback is typically used to improve clinical knowledge and skill development in health sciences students. However, learners often report dissatisfaction with its seemingly one directional, inconsistent, and ad hoc nature. Feedback literacy is one’s ability to recognize, understand, generate, and act on feedback. The concept empowers educators to develop these skills in learners to increase their engagement in the feedback process.

Highlights:

• Create a safe learning environment in which feedback is an expectation.
• Foster the learner’s active role in the feedback process.
• Encourage an appreciation for the intrinsic value of feedback.
• Facilitate learner’s evaluative judgement development.
• Manage emotions.
• Make feedback a focus.
• Encourage peer feedback.
• Use exemplars of high-quality work.
• Use technology to augment the feedback process.
• Continually evaluate and refine feedback processes.
• Start early, repeat, and reflect often.

Nicholas Tripodi , Jack Feehan , Rebecca Wospil & Brett Vaughan (2020): Twelve tips for developing feedback literacy in health professions learners, Medical Teacher, DOI: 10.1080/0142159X.2020.1839035

December 2020: Feedback Resistant Students and Peer Feedback on Teaching Skills
Peer feedback can be a powerful tool. Discussing performance with your colleagues can create a non-threatening environment in which to explore your strengths and weaknesses. These conversations can make us aware of our blind spots, assisting us in improving overall performance.

Highlights:

• Word choice matters. Choose your words carefully.
• Allow the individual being observed to determine the goals of the discussion.
• Maintain confidentiality and focus the conversation on formative feedback. 
• Focus on skills, not personality. 
• Use questioning to uncover teaching goals and perspectives.
• Conclude the process with an action plan.

Lori R. Newman, David H. Roberts & Susan E. Frankl (2019) Twelve tips for providing feedback to peers about their teaching, Medical Teacher, 41:10, 1118-1123, DOI: 10.1080/0142159X.2018.1521953

Feedback in medical education provides important information to foster continual growth. However, the pressures of training and often competitive nature of the environment can shift trainees’ mindset from one of growth to one of outperformance of others. This can lead to feedback resistance in learners, where their ego protects itself against feelings of insecurity and inadequacy.

Highlights:

• We don’t have a clear understanding as to why some students are receptive to feedback while others are resistant to it.
• Resistant behaviors include deflection, constructing mental barriers to receiving the feedback, and demonstrating emotional injury when receiving feedback.
• Increased trepidation with providing feedback may result in a general reluctance to provide feedback at all, which is called vanishing feedback.
• Medical education is caught in a conflict between the need to continually improve with the expectation of excellence or perfection.
• Positive feedback may feel better but does little to ensure maturation of the learner.
• Feedback on the art of medicine is constructive feedback.
• Feedback on the science of medicine is corrective feedback.

Perrella, A. (2017). Room for improvement: Palliating the ego in feedback-resistant medical students. Medical Teacher, 39(5), 555–557.

November 2020: Classifying Feedback in Competency-Based Medical Education
Feedback is an essential component in the teaching-learning process. Feedback can be classified into two forms: Intrinsic and Extrinsic. Intrinsic feedback is driven by the learner, while Extrinsic feedback is driven by instructors. The authors asset that the goal of the curriculum should be to encourage more Intrinsic feedback.

Highlights:

• Students must be assessed frequently, and directive information provided to change behaviors as needed.
• The primary goal of feedback is to aid the learner in achieving their full potential.
• Feedback should focus on learners’ knowledge, skills, and attitudes.
• Intrinsic, or short, feedback takes place when only one person (the learner) is involved.
• Learners engaging in short feedback need self-motivation, self-analysis, and self-directed learning skills.
• Intrinsic feedback requires that the learner be able to distinguish desired performance from actual performance.
• Extrinsic, or long, feedback occurs when two or more people are involved in the feedback process.
• Extrinsic feedback is needed by most students as they are unable to independently discern the difference between desired and actual performance.
• Competency-based medical education (CBME), which focuses on the learner, we may need to transform the way in which we approach feedback, both intrinsic and extrinsic.

M. Senthil Velou, E. Ahila. Types of feedback in medical education – A new hypothesis in alignment with competency-based medical education (PDF). IAIM, 2020; 7(8): 86-90.

October 2020: Individualized Learning Plans for Feedback
Individualized Learning Plans, or ILPs, are supported by self-regulating learning theory, fostering students’ skills in establishing personalized learning goals and plans to achieve them. ILPs encourage reflection, providing a prime opportunity for feedback.

Highlights:

• Focused feedback is more likely to be provided when a learning goal is presented.
• Feedback alignment with learning goals does not necessarily improve the quality of the feedback itself.
• Content, but not quality, of feedback was improved by the presence of a learning goal.
• Different interventions, such as faculty development, are needed to improve the quality of faculty feedback.

Michelle E. Kiger, Caylin Riley, Adrienne Stolfi, Stephanie Morrison, Ann Burke & Tai Lockspeiser (2020) Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students, Teaching and Learning in Medicine, 32:4, 399-409, DOI: 10.1080/10401334.2020.1713790

September 2020: Feedback Seeking Behaviors of Students
Medical students are increasingly viewed as active seekers of feedback rather than passive recipients of information. Students seek information with two goals in mind: learning and performance. In this month’s article, the authors explored the feedback-seeking behaviors of students in the clinical setting.

Highlights:

• Motivation, or self-determination, is the mark of an intrinsically motivated individual.
• High-performing students appear to be more motivated than low-performing students in seeking out feedback.
• Low-performing students may be more externally motivated than their high-performing peers.
• Higher self-determination is linked to greater persistence, better self-perception, and better quality of interactions.
• Higher-performing students appear to seek feedback so they can learn from it, while lower-performing students seek feedback because they are required to do so.
• Higher-performing students appear to recognize the beneficial nature of formative feedback more than their lower-performing peers.
• Student awareness of their motivation to seek feedback may increase self-regulated learning, in that learners may be more inclined to seek formative feedback.

de Jong, L. H., Favier, R. P., van der Vleuten, C. P. M., & Bok, H. G. J. (2017). Students’ motivation toward feedback-seeking in the clinical workplace. Medical Teacher, 39(9), 954–958. https://doi-org.proxy.lib.mcw.edu/10.1080/0142159X.2017.1324948

May 2020: Challenging Feedback Myths
Feedback is often less effective than we want and need it to be. Viewing feedback as a transaction rather than a process limits its effectiveness and may shift focus away from the most important partner in the process: the learner.

Highlights:

• Learners need to develop “feedback literacy,” or the ability and disposition to interpret information and translate it into enhancing their performance.
• Feedback is a process, one that involves bidirectional communication of information that makes a difference in learner’s knowledge, skills, and attitudes.
• The feedback process is longitudinal in nature, occurring over time and involving the learner seeking information to make judgements about the quality of their own work.
• Efforts to balance the message through praise-criticism approaches, such as a the “feedback sandwich,” fail to recognize feedback as a process, focusing on feedback as information to be given rather than interpreted and acted upon.
• Focus on the feedback giving skills of educators fails to recognize the learner’s role in the process and narrows the feedback itself to achievement of competence rather than capability.

Molloy, E., Ajjawi, R., Bearman, M., Noble, C., Rudland, J., and Ryan, A. (2020). Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task. Medical Education, 54, 33-39.

March 2020: Feedback from Medical Students to Faculty
Medical student feedback to faculty is a formalized process in which students anonymously provide unidirectional feedback at the end of a rotation. This feedback is reported to faculty after the rotation ends, ensuring faculty do not alter the student’s performance ratings in an emotional response to the feedback given. While this process serves bureaucratic functions for collecting and recording feedback, and providing data for rank and tenure purposes, it does not foster an environment in which real-time feedback is used to improve instructor performance.

Highlights:

• Research has demonstrated that feedback is effective when given in a real-time format that fosters interaction between the recipient and the provider. 
• The hierarchical nature of clinical learning environments may impede the process of learners providing teaching feedback to their instructors. 
• Faculty report being open to receiving real-time feedback from learners but may be reluctant to accept that dialogue as credible and admit it could bias their grading of students if the feedback received was negative. 
• Faculty willingness to adapt their teaching based on student feedback may be dependent on who is providing the feedback, what information is provided as feedback, how the message is framed, and why the feedback is being given.
• Fostering longitudinal relationships and mitigating the influence of summative assessment may improve the development of trusting relationships that encourage bidirectional feedback. 

Robins, L., Smith, S., Kost, A., Combs, H., Kritek, P.A., and Klein, E.J. (2020). Faculty perceptions of formative feedback from medical students. Teaching and Learning in Medicine, 32(2), 168-175.

February 2020: The Art of Clinical Supervision
Clinical supervision is an important part of health sciences training. Feedback is an essential part of clinical supervision, providing trainees with information and insight designed to improve their development. Therefore, developing comfort in providing and receiving feedback is a vital skill for faculty members to develop.

Highlights 

• Feedback is a two-way, mutually beneficial process. Faculty should expect to give and receive feedback.
• Feedback enhances the understanding of competence and supports targeted learning. 
• Feedback is an emotive form of communication, which can lead to discomfort and avoidance out of fear of damaging relationships.
• In the absence of feedback, students are left confused and unsure about their level of practice.
• Supervisors often lack confidence in their ability to provide feedback, particularly when there are concerns regarding a trainee’s performance. 

Suggestions:

• Use Bloom’s Taxonomy to plan, deliver, and evaluate learning, which includes provision of feedback.
• Incorporate both formative and summative feedback into your teaching processes. 
• Focus feedback on knowledge, skills, and attitudes. 

Russell, K. (2019). The art of clinical supervision: strategies to assist with the delivery of student feedback. Australian Journal of Advanced Nursing, 36(3), 6-13.

January 2020: Broadening the Scope of Feedback
The assumption that providing “good” feedback will result in better learning and performance fails to consider the complexity of learning and behavior change. The historical viewpoint of unidirectional feedback has not yielded the desired outcomes. As such, it may be time to broaden the definition of feedback in the workplace to align it with the complexity of social learning processes.

Highlights:

• Feedback should be redefined as performance-relevant information, or PRI.
• “Relevant information” provides a more neutral term, whereas “feedback” denotes a judgement is being made. 
• PRI appreciates the importance of what the learner considers relevant for their own learning. 
• PRI focuses on how learners interpret workplace information related to their own learning needs. 

November 2019: The Feedback Tango
Feedback is a dynamic partnership, one in which both partners play a role. This relationship proves difficult in medical education, with learners often reporting they do not receive sufficient feedback. An exploration of the content of feedback may shed some light on why the feedback relationship in medical education proves challenging.

Highlights: 

• Feedback providers are typically reluctant to provide constructive or negative feedback to learners. 
• Formal feedback tools did not mitigate the tendency to provide predominantly positive feedback.
• Partners in the feedback relationship need to be open to responding to one another appropriately rather than enter the exchange with a set idea of how they will respond.
• The feedback partnership should be one of mutual respect, care for one another’s success, and provision of a psychologically safe environment in which the partners feel comfortable discussing shortcomings.

Bing-You, R., Varklis, K., Hayes, V., Trowbridge, R., Kemp, H., and McKelvy, D. (20198, April. The feedback tango: An integrative review and analysis of the content of the teacher-learner feedback exchange. Academic Medicine, 93(4), 657-663.

October 2019: Providing Teaching Feedback to Peers
Peers can serve as “critical mirrors” that reflect back to us things we can’t see about ourselves. Such is true in life and in teaching. Peer-to-peer feedback conversations typically focus on a discussion of optimal teaching strategies and an exploration of solutions to difficult challenges rather than a plan for improvement. These conversations are formative and collaborative, not evaluative, in nature.

Highlights:

• Let the observed party, or “host,” set the goals for the observation to help them target their own needs. 
• Establish confidentiality rules. Build a trusting relationship to foster honest and open communication. 
• Focus on skills, not the person.
• Be mindful of pronoun usage. Use “You” statements when giving praise and “I” or “We” statements when suggesting changes.
• Be aware of your own personal biases, such as halo or horn effects. 

Newman, L.R., Roberts, D.H., and Frankl, S. E. (2019). Twelve tips for providing feedback to peers about their teaching. Medical Teacher, 41(10), 1118-1123.

September 2019: Seeking Feedback
The feedback relationship is a complicated one, influenced by numerous factors. When developing a feedback relationship, it is important to remember that feedback is a two-way dialogue and not a one-way transmission of information. Feedback given is not necessarily feedback received, nor does feedback being sought mean the recipient is ready to openly receive and act upon it.

Highlights:

• Students may confuse formative feedback and summative assessment, distorting their perceptions and reactions to feedback.
• Students may observe for clues, such as provider mood, before seeking feedback.
• Faculty need to move beyond simply telling students to ask for feedback and better prepare them to receiving and acting on it. 

Bing-You, R., Hayes, V., Palka, T., Ford, M., and Trowbridge, R. (2018, August). The art (and artifice) of seeking feedback: Clerkship students’ approaches to asking for feedback. Academic Medicine, 93(8), 1218-1226.

August 2019: Establishing a Positive Learning Climate
Establishing a positive learning climate helps teachers and learners overcome the natural tendency toward trepidation regarding feedback. Prepare a foundation on which learners expect growth-enhancing feedback and feel comfortable accepting constructive criticism of their performance.

Highlights:

• Set the expectation that you will facilitate frequent, formative feedback conversations.
• Focus on goals and observed performance when providing feedback.
• Role model positive behaviors, such as demonstrating respect, a willingness to welcome opinions and a readiness to admit your own limitations and errors.
• Foster relationships that encourage two-way feedback, allowing the learner to provide formative feedback to you as a teacher.

Ramani, S., Konings, K.D., Ginsburg, S., Ginsburg, S., and van der Vleuten, C.P.M. (2018, February). Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships. Medical Teacher, 41(6), 625-631.

May 2019: Feedback Redefined
Competency-based medical education relies on formative feedback to provide learners with information essential to their continued growth and development. Unfortunately, trainees often report that meaningful feedback is infrequently provided. Newer models of feedback emphasize the role of the learner in the process, making them an active participant in receiving and acting on feedback throughout the course of their training.

Highlights:

• The landscape of feedback needs to shift from feedback techniques to the goals, acceptance and assimilation of feedback by learners. 
• The feedback loop is incomplete until learners act on the feedback they are given.
• Medical education environments need to promote trusting relationships between teachers and trainees to enable meaningful exchange feedback.
• The goal-orientation of learners may have a strong influence on their ability to seek and receive feedback.

Ramani, S., Konings, K.D., Ginsburg, S., and van der Vleuten, C.P.M. (2019, February). Feedback redefined: Principles and practice. J Gen Intern Med, 34(5), 744-9.

April 2019: Feedback Seeking Behaviors of Students
Medical students are motivated by several factors when deciding whether to seek feedback. Bing-You et al. found that students observe their faculty and residents for cues before engaging in a feedback dialogue. To encourage feedback seeking behaviors, faculty should be supportive and constructive when providing feedback.

Highlights:

• Feedback is a two-way dialogue and not a one-way transmission of information. 
• Feedback seekers may tend toward a "learning goal" orientation as opposed to a "performance goal" orientation. That is, their focus may be more on learning than receiving a positive assessment. 
• Learners' feedback seeking behavior may be influenced by the trainer's leadership style, with supportive leaders inspiring trainees to engage in more feedback in shaping their seeking behaviors. 
• Learners often weigh the perceived benefits and costs of the feedback in shaping their seeking behaviors.
• Faculty need to do more than tell students to seek feedback; they need to foster an environment that encourages and nurtures such behaviors. 

Bing-You, R., Hayes, V., Palka, T., Ford, M., and Trowbridge, R. (2018, August). The art (and artifice) of seeking feedback: Clerkship students’ approaches to asking for feedback. Academic Medicine, 93(8), 1218-1226.

March 2019: Meaningful Feedback Conversations
LaDonna and Watling (2018) provide a commentary on their study of feedback in the clinical learning environment. Human motivation is complex, and their findings suggest that formal programs may not overcome lack of internal motivation when it comes to engaging in a meaningful feedback conversation.

Highlights:

• Various forces can discourage learners and faculty from engaging in meaningful feedback conversations.
• Learners develop their knowledge and skills in a culture permeated with messages about competence and independence, making the vulnerability of honest feedback uncomfortable.
• Observation and feedback are often viewed as something from which you graduate rather than something that you integrate into practice.
• Learners may view feedback as a bureaucratic process rather than a learning opportunity.
• Driving meaningful feedback may require a culture change in medicine that embraces vulnerability.

LaDonna, K.A., and Watling. C. (2018, February). In search of meaningful feedback conversations. Medical Education, 52(3), 250-251.

February 2019: Feedback and Culture Development
Establishing healthy feedback relationships relies on development of a positive feedback culture. Such a culture includes interpersonal relationships and institutional context.

Tips for developing a feedback culture:

• Be a professional role-model and establish a positive learning environment
• Conduct direct observation to inform your feedback
• Facilitate reflection and self-assessment in your learners
• Foster a growth mindset in your learners
• Encourage feedback seeking behavior
• Promote learner-initiated action plans
• Establish an educational alliance
• Encourage co-creation of learning opportunities
• Promote balance between supervision and autonomy
• Establish a continuous practice improvement environment
• Create a culture that emphasizes personal growth

Ramani S, Konings KD, Ginsburg S, van der Vleuten C. (2018). Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships. Medical Teacher. DOI: 10.1080/0142159X.2018.1432850

January 2019: Feedback and Relationship Development
Teaching and learning is a sociocultural process, one in which relationships between parties play an important role. Feedback relies on development of effective relationships.

Points to consider:

• Effective feedback interactions require an alliance between the teacher and the learner, with the learner taking an active role in the process.
• A culture of politeness, while fostering positive relationships, can hinder honesty in the feedback process.
• Key aspects of a feedback culture include feedback providers, feedback receivers, the feedback relationship, and institutional context.

November 2018: Faculty Behavior: Helping Students Develop an Action Plan
Communicating strengths and weaknesses in a student’s performance is only part of the feedback process. Good feedback includes assisting the learner in identifying next steps and developing an action plan to address areas for improvement.

Tips for helping develop an action plan:

• Help learners identify new approaches to an identified problem.
• Provide guidance to learners who understand they need to make a change but don’t know how to do so. For example, when a student understands they need to communicate differently but don’t know what that means from an action standpoint.
• Help learners overcome barriers to meeting their change goals, such as how to avoid being overwhelmed by their own emotions when using empathy with patients.

Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. 

September 2018: Faculty Behavior: Elicit Learner's Thoughts and Feelings
Feedback should be given when the learner is able to process it. At times, that will mean the feedback giver needs to attend to the thoughts and emotions the learner is experiencing prior to, and even after, the feedback is given.

Tips for attending to emotions:

• Conduct a debrief regarding the emotional aspects of an encounter prior to giving feedback. Ask the learner how they felt in the encounter or offer an observation about emotions you witnessed.
• Role model appropriate emotion handling skills.
• Give the learner the time and space they need to handle their emotions so they can learn from the feedback when it is given.
• Check in with the learner after giving feedback to address their emotional state. Use supportive phrasing and questioning to minimize defensive reactions.

Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

July 2018: Relate Feedback to Specific Behaviors
Feedback should be a routine activity, woven into the culture of learning. Faculty should strive to provide feedback that is directly related to specific learner behaviors with the goal of helping students self-reflect and modify their performance.

Tips for relating feedback to behaviors:

• Discuss the learning objectives with the learner before observing their performance.
• When observing, take note of behaviors that relate to the learning goals.
• Use specific, nonevaluative language to convey observations (e.g., “I noticed you decided to do X” rather than “You should have done Y”).

Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

June 2018: Consider the Setting
Faculty should be mindful of the setting when gauging what and how much feedback to provide. Keep in mind the level of privacy provided by a particular setting and the learner’s ability to receive feedback given the day’s workload.

Tips for selecting the context of feedback:

• Provide feedback in a private setting whenever possible.
• Set aside time for you and the learner to focus on the feedback without extraneous distractions.
• Focus on one or two skills or behaviors during the feedback session to avoid overwhelming the student’s ability to process the information you provide.

Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

May 2018: Establishing Goals
Faculty can initiate the process of establishing goals by asking the learner to define what they want to work on given their personal stage of development. Learner-driven goal setting helps the goals to feel more relevant, better engaging the learners in behaviors to meet them. However, faculty should not refrain from suggesting and augmenting goals as they deem appropriate given their observations and expertise.

Tips for establishing goals:

• Initiate the goal setting process at the beginning of the teacher-learner interaction.
• Invite the learner to identify their personal goals (and challenges) to engage them in an interactive process of establishing objectives.
• Refine goals throughout the teacher-learner relationship, noting learner development and continuing to challenge them to reach the next level.

1Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

February 2018: Faculty Behavior: Reflecting on Observed Behaviors
One faculty behavior that affects the efficacy of feedback is reflection on observed behaviors1. Reflection allows the teacher to compare the learner’s performance against the learning goal(s) and tailor their feedback to the specific learner’s needs.  Ideally, the reflection process includes faculty and learner reflection to foster collaboration and establish mutual goals.

Tips for engaging in reflection:

• During the observation, take note of the learner’s performance as it relates to the learning goals.
• Ask the learner to reflect on their performance to help you focus what feedback you provide. This can be particularly important when learning goals were not communicated prior to the observation.

Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

January 2018: Improving the Efficacy of Feedback
Research suggests that students value feedback, considering the ability to provide it effectively as an indicator of good teaching1. However, it is important to note that student satisfaction with feedback is not indicative of its effectiveness. Rather, the feedback process should strive to make areas for improvement known in a way that allows the learner to engage in self-reflection and implement changes to their performance. Below are behaviors or skills research specifies may improve the efficacy of feedback.

Faculty behaviors or skills

• Establish an appropriate interpersonal climate
• Use an appropriate location
• Establish goals
• Elicit learner's thoughts and feelings
• Reflect on observed behaviors
• Be non-judgmental
• Relate feedback to specific behaviors
• Offer the right amount of feedback
• Offer suggestions for improvement
• Handle conflict proficiently
• Have your own professional goals set in the last year
• Allow learners to figure things out, even if they struggle

Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

November 2017: Goal-Oriented Feedback
Feedback is information on performance as it relates to a goal. While it can be, and often is, paired with guidance or advice, feedback itself is devoid of judgment or valuation. Simply put, feedback is a statement of what is or isn't.

Grant Wiggins (educator and author, "Seven Keys to Effective Feedback") tells us, "Information becomes feedback if, and only if, I am trying to cause something and the information tells me whether I am on track or need to change course." Without a goal in mind, attempted feedback is just more information for the learner to try to process.

Key points:

• Remind the learner of the goal
  • "Your goal is to obtain a thorough history from the patient. You forgot to ask about social history. What could you have asked to get the information you need?"
• Be sure the feedback is based on what you observed
  • "Your differential did not include the possibility of disease X."

Wiggins, G. (2012, September). Seven keys to effective feedback. Educational Leadership, 70(1), 10-16.

October 2017: When Feedback is Effective
Feedback can be an important educational tool to foster continual reflection and growth. It is dependent on effective instruction, goal setting, and students’ understanding of the assessment process.

Effective feedback relies on communication and interpretation, with the instructor and learner establishing shared goals for achievement and engaging in recurrent communication to foster growth. Learners need guidance on how to revise their current performance to achieve the desired standard. This information reduces the cognitive load so the learner focuses their energy onto the specific aspects of their performance that warrant improvement.

Key points:

• The success of the feedback process rests in the student’s ability to receive information and interpret it effectively.
• Feedback needs to engage the learner at, or just above, their current level of performance.
• Feedback should reassure the student that difficulties in achieving mastery are to be expected, encouraging them to invest the effort necessary to improve.
• Feedback is enhanced in an environment where errors and discomfort are treated as natural aspects of the learning environment.

Hattie, J.A.C., & Yates, G.C.R. (2014). Using feedback to promote learning. In V.A. Benassi, C.E. Overson, & C.M. Hakala (Eds.). Applying science of learning in education: Infusing psychological science into the curriculum. Retrieved from the Society for the Teaching of Psychology website.