Ingredients of Effective Feedback
Giving feedback is a skill that deserves practice and conscientiousness. Here are some key points to enhance your efficacy.
Ensure you are in an appropriate setting, both physically and psychologically. Find a place that is quiet and private, where you both can feel vulnerable. The setting should also be one of psychological safety, established early in the relationship, in which admitting weaknesses and acknowledging failures is okay.
On my first rotation in rheumatology as a medical student, I asked if it would be okay to go to lunch. My supervisor said, “Michael, this is rheumatology,” and smiled reassuringly. Myriad ways exist to make learners feel welcome and establish psychological safety. Find the ways that feel most genuine.
Timing is key. Did your fellow just get three new consults or finish a long clinic day with several notes to write? If so, it may not be the ideal time for feedback. If you notice they are struggling in the moment, make a physical or mental note and return to your note for feedback later. At the beginning of a rotation, set expectations that you will be providing feedback and hope to receive specific feedback as well. During this conversation, you can ask your trainee about preferred and off-limit times for feedback.
Make your feedback specific. It is extremely important to comment on behaviors and actions that you observed (e.g., “Based on our encounter with Mr. Jones yesterday, I noticed you didn’t have a robust schema for diffuse lymphadenopathy.”) rather than on generalized personal characteristics (e.g., “You don’t seem intellectually curious.”). This provides your trainees with objective data they can correct, as opposed to a judgment about their intentions based on your interpretation of their behavior and actions.
It can be difficult to remember particular moments to reflect on, however, so develop a system to track memories of your time working together. Some faculty find it helpful to keep a running list of moments on their phone’s “Notes” application, while others prefer pen and paper. Sometimes reviewing text threads between you and a fellow can also elicit memories of specific patient encounters.
Feedback should include a mix of reinforcing and modifying feedback. Reinforcing feedback is typically positive (e.g., “You did an excellent job using simple yet compassionate language to explain the new diagnosis to the patient.”) and encourages a trainee to continue a certain practice. Modifying feedback, on the other hand, ultimately redirects behavior (e.g., “Next clinic, try standardizing your approach to the joint exam with each patient.”).
Data show a high ratio of reinforcing to modifying feedback, at 5:1 or greater, is optimal for team performance, although one could argue that in an ideal culture of coaching and growth this ratio can be lower.5 What is clear is that reinforcing feedback is just as important as modifying feedback, and encourages good practices, bolsters confidence and promotes supportive coaching relationships such that trainees are more receptive to modifying feedback.
Engage your trainees in setting specific goals for their growth. Initiate a dialogue in which you can co-create goals and action plans and agree on when it would be appropriate to check in again. Your fellow may say, “I’d like to get your thoughts on how I’ve been managing the initial work-up of new consults. Can we touch base at the end of this week?”
Getting your learners’ buy-in gives you a starting point for beginning the conversation at your next feedback session (e.g., “You were aiming to improve your approach to the work-up for new consults. What have you done effectively in this regard?”). Remember, it’s the learners who decide whether to incorporate modifying feedback, so engaging them through goal setting increases their receptivity.
Finally, don’t overload your learner with feedback. Daily, informal snippets of feedback can be excellent, especially if they are reinforcing (e.g., “I wouldn’t have done the knee arthrocentesis any differently.”). However, be intentional about creating time and space for longer, summative feedback conversations at regular intervals. At minimum, you should meet at the halfway point to develop and enact action plans, and again at the end of the rotation to reflect on your time together. Fortunately, most rheumatology divisions are small, meaning plenty of opportunities exist for direct observation of trainees and to pick up where you left off.
