Effective Feedback: The Heart of Medical Education!

This week, lets talk about FEEDBACK. This is something which we should do everyday, may be after every shift or may be twice/thrice on a single shift. An effective feedback can really transform learners. This is important for the attendings /consultants as well as the residents as they need to provide constant feedback to the residents/ medical students. 

So, What is feedback?

Feed- back is an essential element of medical educational that can help students/residents to reach the best of their potential. It enables the learner to achieve goals by reinforcing good performance and providing the basis for remediation whenever required. Feedback, therefore, drives learning and progress and is essential in allowing a student to remain on course in reaching a goal. Its also a good spot where learners can pause and reflect back on their own performance. 

Adult learners welcome feedback, especially when it is based on their performance and tailored to their goals.

Providing feedback is an art which can be acquired overtime with practise. Often this is ignored in medical education and teachers/ instructors are not taught on "how to provide an effective feedback". This is a really critical component and it should be a part of our training. If feedback is not provided, then poor performance will remain uncorrected which while eventually get passed on to the next generation of learners!

The Goals of Feedback:

• Encourage learners to self reflect and think how they might improve 

• To narrow down the gap between actual and desired performance 

• Lead to changes in the learner’s thinking, behaviour, and performance 

Note: Feedback is not given to make someone feel good, but for them to reflect back and improve their performance.  It is intended to change behaviour, rather than being an estimate of the students’ worth.

Characteristics of Constructive Effective Feedback 

1. Timely 
2. Specific 
3. Non Judgemental
4. Non Threatening 
5. Constructive 
6. Measurable 
7. With opportunity to respond 
8. Motivating
9. Clear summary and follow up
10. Conclude with an action plan

Often we hear feedback like "Good Job" - "Keep it up" - "Well Done" which is essentially meaning less. Feedback should be very specific mentioning about what went well and what could have been done better. So don't just say "Good job" next time - Be specific. As educators we also might find it difficult to provide negative feedback. A good way to do that is:

The Approach to Providing ‘Negative’ Feedback 

• Goal is improvement – ALWAYS 
• Relaxed environment
• Let the learner self-evaluate first (You will be surprised to know that how critical they can get about themselves) 
• Offer positive feedback, too – focus on the work, not the person
• Offer specific ways to improve
• Also you can ask for feedback from them on how you can improve as an educator

When feedback fails, it is because the process was handled poorly, causing defensiveness and embarrassment to the learner and leaving them feeling demoralised and rejected. Therefore, Attending training programmes on how to give feedback should be essential for those who teach in medicine because, in trying to give feedback, we still make remarks that have the potential to undermine the learner’s confidence completely.

Methods of Providing Feedback 

1. FAST – frequent, appropriate, specific, timely 
2. W3 – what went well, what didn’t go well, what could you work on 
3. ARCH – ask, reinforce positives, correct negatives, help move forward 
4. 360 approach – seek feedback from all team members (nurses, pharmacists, patients, etc.) 
5. Feedback Sandwich – positive → negative → positive 
6. One minute preceptor – have the learner commit to a plan, have the learner provide support/evidence for their plan, discuss general rules applied to this plan and future plans, reinforce what was done well, provide constructive feedback on areas in need of improvement, identify learning steps 
7. Pendelton: Pendleton’s rules are structured in such a way that the positives are highlighted first, in order to create a safe environment.Therefore the learner identifies the positives first. This is followed by the facilitator or group reinforcing these positives and discussing skills to achieve them. “What could be done differently?” is then suggested, first by the learner and then by the person or group giving feedback. 

 What you should never do while providing feedback! Never!

• Don’t form opinions based on what you’ve heard 
• Don’t compare to other students 
• Don’t focus only on the ‘negative’ 
• Never be sarcastic 

Don't say things like: that was awful, you are stubborn/narrow minded, I will take you for a task next time if you repeat this, better do it right next time, Are you a real doctor or a quack?

It makes me really sad and upset when I hear such comments. Residents and medical students frequently receive feedback that leaves them feeling bruised, depressed and lacking in self-worth. It is not surprising then, that medical teachers brought up in this environment, avoid giving feedback – especially if it is ‘corrective’.

Providing Feedback to the Millennial Learner (born ~1981-2000) 

• Millennial learners expect to be entertained while being educated - 
• Despite the incorporation of technology into most aspects of their lives, they actually prefer face-to-face or written feedback 
• They prefer private feedback 
• They seek immediate feedback, both positive and negative 
• Millennial learners assume positive if no feedback given 

Key Points 

• Feedback is about communication. The key skills are to listen and ask, not to tell and provide solutions. Be specific, be clear.
• Learn this with practise - See which method works out for you.
• Most important: Always Be sensitive and be NICE!

Further Reading:

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496906/
2. http://onlinelibrary.wiley.com/store/10.1576/toag.6.4.243.27023/asset/toag.6.4.243.27023.pdf;jsessionid=5C493ACD23451626AC8FE1B6C5A015A3.f02t03?v=1&t=i83v9qqv&s=e2686ad66f4489b268a22429ea795c689454ea9c
3. http://sse.umontreal.ca/apprentissage/documentation/Ramani_KracKov_2012_Tips_Feedback.pdf
4. http://new.livestream.com/iTeachEM/events/2539760/videos/49556191