Oct 30, 2019, 15:43 PM by Celeste Quan, MBBCh, DA, FCA, and Ki Jinn Chin, MB, BS, FANZCA, FRCPC

Effective feedback is vital in clinical training. It allows trainees to reflect on their development, trainers to assess progress, and both to identify areas for development. In other words:

• “Where am I going?” (What are my goals?)
• “How am I going?” (What progress is being made toward the goal?)
• “Where to next?” (What needs to be done to make better progress?)

Feedback as a Tool

Feedback, both positive and negative, can be a powerful educational tool.^[1] Conversely, if given incorrectly, feedback can be destructive and should be avoided. Unfortunately, lack of feedback is one of the most serious deficiencies in current medical education practice.^[2] The primary reasons are that educators may not fully appreciate the role of feedback as a fundamental clinical teaching tool and may not be skilled in the process of providing high-quality feedback.^[3]

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Feedback, both positive and negative, can be a powerful educational tool. Conversely, if given incorrectly, feedback can be destructive and should be avoided.

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Levels of Feedback

Feedback can relate to the following levels:^[1]

1. Task (eg, performing an interscalene block under ultrasound guidance)
2. Processing the task (eg, understanding the anatomy of the brachial plexus in the interscalene area)
3. Self-regulation or self-evaluation and the ability to engage further on the task (eg, “How do you think your block went, and how can we do it better in the future?”)
4. Personal (eg, “Your needling technique is poor.”)

Feedback about the person is too often used instead of feedback relating to the first three levels. It usually contains little task-related information and rarely translates to more engagement, commitment to learning, self-efficacy, or understanding. Feedback that is directed at the personal level can improve learning only if it leads to changes in a trainee’s effort, engagement, or feeling of efficacy.^[1]

Timing of Feedback

Depending on the type of training, feedback can be delivered either immediately while the event is happening or later when reflecting on the event.

Task or Specific Skill

Immediate, informal feedback is likely to be more effective when relating to task performance, whereas delayed feedback may be more useful in discussing processing of a task. The optimal timing of feedback may also depend on the complexity of the task at hand. Difficult tasks are likely to involve more processing, and delayed feedback provides an opportunity to analyze that in appropriate detail.^[4] Drowning a trainee with information in the heat of the moment may be overwhelming and result in poor retention.^[5]

Course or Rotation

A longer, formative feedback session should be scheduled midway through a course or rotation. If behavior requires correction, feedback should take place as soon as possible. This allows a learner time to remediate before the end of the course.^[6]

Feedback Environment

The feedback environment should be one of mutual trust and respect. The teacher and the trainee are partners in the process.

Bing-You et al. demonstrated that feedback given in a private setting might be more effective.^[7] However, feedback may also be received differently depending on the cultural background of the learner. Learners from collectivist cultures (eg, Confucian-based Asia, South Pacific nations) prefer more group-focused feedback. Learners from individualist cultures (eg, the United States) prefer more individual-centered feedback.^[8]

Models for Giving Feedback

Different situations require different delivery methods for feedback. Several established models exist.

Replaying the Event

This is the simplest of all models. A trainer takes the trainee chronologically through an event and gives feedback at every step, as required. This model is most suitable for one-on-one and short feedback sessions.^[9]

Feedback Sandwich

In this model, positive feedback is delivered both prior to and following constructive criticism of an area deficient in performance. This model may make a trainee more receptive to criticism and prevent them from feeling too disheartened at the end of the feedback. The biggest disadvantage of this model may be that the learner may not listen to the positives and instead wait for the impending negative feedback.^[9]

Pendleton’s Rule

Pendleton introduced the following model in 1984 to provide feedback in advanced life support training:^[10]

• The trainee describes what went well.
• The trainer states what the learner did well.
• The trainee identifies what could be improved.
• The trainer recognizes areas for improvement and how to achieve this.

Pendleton’s rule helps develop self-reflection and encourages two-way communication. It is most useful for providing feedback for practical skills but can be too systematic and rigid.

Agenda-Led, Outcome-Based Analysis

This model is based on identifying a learner’s agenda from the outset and what he or she needs help with. A trainer focuses on the outcomes the learner has chosen in assessing performance and giving feedback. The model may be particularly suited to feedback related to a course or rotation, or to theoretical learning. It can be adapted to specific tasks, especially with advanced trainees who are aware of their limitations and the demands of the task, and who are seeking to refine certain aspects of their performance.^[9]

Learner-Centered Model

In this model, the learner takes responsibility for the whole process of feedback, including seeking, preparing, and benefitting from the potential feedback. It is only suited for learners who are self-efficient (receptive, reflective, and responsive).^[9]

Principles of Giving Effective Feedback

Following these key strategies helps trainers offer the most successful feedback: ^[11]

• Feedback should be specific and based on direct observations (eg, “I noticed that . . .” or “I saw that . . .”).
• Focus on performance of the task (eg, “You performed that block really well because you understand the anatomy”), not on the individual performing the task (eg, “Good girl”).
• Language should be specific, neutral, and nonjudgmental (eg, “Before you perform the block, make sure you have identified the blood vessels and plan a path for your needle to avoid them” instead of “The way you performed the block was dangerous”).
• Emphasize positive aspects and be descriptive rather than evaluative.
• Reinforce exemplary behavior, which will give learners confidence in their skills.
• Highlight areas and measures for improvement.
• Conclude with an action plan.

Effective Informal Feedback

The following questions may help trainers provide informal feedback about any educational activity:^[9]

• Did the procedure go as planned? If not, why not?
• If you had to do it again, what would you do the same or differently? Why?
• Did you feel tentative, confident, or out of your depth? How would you feel if you did the procedure again?
• How do you think the patient felt? What makes you think that?
• What did you learn from this?

Feedback on performance can help a learner to advance from beginner to an expert in four stages, as shown in Table 1.

Table 1. Role of feedback in performance development.^[12]

	Stage	Learner	Role of feedback
1.	Unconscious incompetence	Unaware of weaknesses	Helps learner recognize weaknesses
2.	Conscious incompetence	Aware of weaknesses but lacks skills to improve	Helps learner define and refine skills
3.	Conscious competence	Demonstrates competence but not fully integrated	Helps learner refine skills and encourages through positive feedback
4.	Unconscious competence	Carries out tasks without conscious thoughts	Builds on strengths, identifies weaknesses

Common Mistakes When Giving Feedback

Avoid pitfalls that make the feedback experience counterproductive for trainers and learners.^[9]

• Giving feedback when it is not asked for or when a trainee is not receptive
• Bringing up previous mistakes (unless the aim is to address a repetitive pattern of behavior)
• Focusing on personal issues, such as personality. Treat the criticism as an abstract problem, not a personality defect.
• Giving negative feedback in front of an audience instead of privately
• Overloading the trainee
• Giving feedback when angry
• Providing immediate feedback for a situation that could have had serious adverse events. The first response should be to provide trainees with emotional support. Feedback for the purposes of learning from the incident should be deferred to a later debriefing session in a supportive environment.^[13]

Conclusion

Delivering effective feedback is an essential part of medical education and can be rewarding for trainers. Learning to give effective feedback takes practice. Remember that in reflecting on your feedback skills, you can turn the tables on yourself and request feedback from your trainees on your performance as a teacher. Feedback should be part of institutional culture and is key to continued improvement in standards of care.^[6]

References