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Explore This IssueJuly 2017
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I was driving to work one morning when I stopped behind a truck at a red light. The driver had placed several flashy stickers on the bumper and back doors. But what I was drawn to was a more commonplace sign: “How’s my driving? Call this number to give feedback.”
It’s routine to find a sign like that on commercial trucks, but what made it memorable was that the last two digits of the phone number were completely covered by a thick layer of dirt and mud. I could not give him any feedback, even if I tried. As I drove onward, I thought, “Maybe that was by design.”
In many ways, that’s how feedback is during residency and fellowship. Everyone says that feedback is welcome, but when it comes to actually giving it—or taking it—there’s a major disconnect between words and action. And that’s too bad, because, arguably, feedback is at the heart of education.
Feedback is a form of formative evaluation, a way of sculpting ourselves in small but meaningful ways so that we can get to our personal best. Without feedback, we can only fall behind others as they improve.
With that in mind, here are six tips to keep in mind when giving (and receiving) effective feedback:
1. Feedback Is Neither Positive nor Negative
We tend to think of feedback in biologic terms, with it being either positive or negative. But that scale doesn’t fit when it comes to feedback. Feedback is high quality or low quality.
Most trainees are intimately familiar with the crap sandwich, the type of evaluation that starts with something good but then turns nasty and negative, and finishes off on a vaguely sweet note. When structured in that way, feedback becomes stigmatized and inauthentic. The words of the evaluator become less and less meaningful, and the entire encounter becomes stressful in anticipation of getting to the bad parts. That’s low-quality feedback, and sadly, that is ubiquitous.
2. Feedback Must Be Objective
Instead of the crap sandwich, I recommend a more nuanced approach. Instead of appraising first (“I like what you are doing but …”), start with observations (“I’ve noticed that you do this”). That takes a lot of the broad-based judgment out of feedback sessions. It also invites the learner to think about and comment on their habits, leading to action rather than dwelling on what has already been done and can’t be changed.
In addition to softening the judgmental overtones often associated with feedback, the appraisal can be more nuanced and personalized. Of course, there will always be an element of subjective judgment, but acknowledging when that occurs can help divorce it from becoming a matter of opinion that a learner may not necessarily take seriously.
3. Feedback Has to Be Signposted
Because feedback is so critical to medical education, you would be surprised how often you have received it and haven’t even realized it. Studies have shown that learners tend to underestimate the amount of feedback they receive, especially when it is not given in a timely manner.1,2 In order to get credit for giving and receiving feedback, educators really should declare that they are giving feedback. For example, with medical students, I often start with, “I’m going to provide some feedback here,” and end with, “What other feedback would you like?” It may come off as a little forward, but I don’t see much virtue in subtlety.
4. Feedback Must Be Valuable
When it comes to feedback, less can be more. A few impactful points are more useful than long discussions. Vague, if standard, compliments, such as, “You really did a good job,” should be avoided. After all, what does “a good job” mean, and why does it matter if a learner did a good job? The value of feedback is also dependent on the rapport between the learner and the teacher. If feedback is not geared toward and customized for the situation and the learner, then there really is no underlying communication of the message.
Feedback is a form of formative evaluation, a way of sculpting ourselves in small but meaningful ways so that we can get to our personal best.
5. Feedback Is a Two-Way Street
One of the ways to ensure authenticity is to level the playing field. A heavy-handed approach to giving feedback is unlikely to have an intended effect. Instead, honesty and frankness have to be emphasized, which necessarily means that we have to suspend the hierarchies that are endemic to medical education. This is obviously much easier said than done. I recommend that after each feedback session, the evaluator ask, “What questions do you have for me?” Or better yet, “What feedback can you provide for me?”
6. Feedback Requires Constant & Disciplined Practice
I’m not sure anyone can become perfect at giving or receiving feedback. I think the challenge of feedback is that it has to be intimately personalized. There’s no one-size-fits-all formula. It has to be individualized for each situation and person. Many learners are incredibly resistant to receiving feedback, which underscores the need to be consistent and fair in giving feedback. In fact, feedback on feedback needs to be periodically given, whether by learners or by colleagues.
Feedback is a powerful tool to advance education, but in the end, it is only as good as its user. Feedback has to be honed, carefully and intently, so that it can become more versatile. It has to leap from being regarded as a simple buzzword into something that actually has meaning for both learners and for teachers.
It’s not as easy as putting up a bumper sticker and forgetting it, but if it were that easy, it probably wouldn’t be worth it.
Bharat Kumar, MD, MME, RhMSUS, is a clinical assistant professor of internal medicine at the University of Iowa. He completed a dual fellowship in rheumatology and allergy/immunology, as well as a Master’s in Medical Education in 2017. He has a special interest in journalism, healthcare policy and ethics. Follow him on Twitter @BharatKumarMD.
- Al-Mously N, Nabil NM, Al-Babtain SA, et al. Undergraduate medical students’ perceptions on the quality of feedback received during clinical rotations. Med Teach. 2014 Apr;36(Suppl 1):S17–S23.
- Gran SF, Brænd AM, Lindbæk M, et al. General practitioners’ and students’ experiences with feedback during a six-week clerkship in general practice: A qualitative study. Scand J Prim Health Care. 2016 Jun;34(2):172–179.