Teaching The Trainer: How To Give Feedback - Medicine

How to Give Feedback
Linda A. Waggoner-Fountain, M.D.

I have no disclosures to state. I do have my
own opinions.

Learning Objectives
• In this workshop, we will
– Review basic principles of effective feedback.
• Following this session, participants will be able to:
– Describe what feedback is and what it is not
– Describe how and when to give feedback
– Develop skills in giving feedback
– Recognize the importance of providing feedback.

Feedback - Definition
Interactive process aimed at
reinforcing positive behavior and
providing specific guidelines for
future behaviors
“corrective” – negative
“reinforcing” – positive

Characteristics of Good Feedback
• Video

Feedback – Why is it important?
• Feedback is central to medical education
in:
– promoting learning
– ensuring that standards are met
• Provides:
– Student/resident with an accurate perception
of their own performance
– Enhanced student/resident self awareness

Room for improvement
• Residents report feedback is not common
– In one study, only 8% of residents were “very
satisfied” with feedback process
• “Corrective” feedback much less common than
“reinforcing” feedback
– Reinforcing feedback
• Never or infrequently receiving 17%
• Sometimes receiving 52%
• Often receiving 34%
– Corrective feedback:
• Never or infrequently receiving 80%
• Sometimes receiving 20%
• Often receiving 0%
Isaacson et al 1995

Feedback? Coaching?
Performance Evaluations?
Feedback Coaching Performance
Evaluation
Purpose To reinforce or
change behavior
Participants Any ≥ 2 people Typically supervisor to
direct report but can be
multidirectional
Place Private and quiet
space
To improve skills To evaluate past work
Depends on the skill to
be learned
Tone Casual, can be formal Somewhat formal, but
potentially relaxed
Timing Impromptu prn or
during formal
sessions
Supervisor to direct
report
Usually in the
supervisor’s office
formal; often stressful
Regular meetings Scheduled, e.g. q 6
mos or yearly
Follow-up Continual Continual Based on action plan

Obstacles for Teachers
• It can be uncomfortable giving negative
feedback
• Concerns about consequences of negative
feedback
• Time constraints
• Poor feedback skills
• Unaware of the importance of feedback
• Limited knowledge about the performance

Obstacles for Receiving Effective
Feedback
• Perceived as personal judgment
• Inconsistent messages
• Inappropriate environment
• Different goals
• Too busy

What Are The Critical
Elements In The Feedback
Process?

Critical Steps
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

Study
• Study: Clinician teachers’ personal experiences during a
course for improving teaching of medical interviewing
– 83 physicians/scientists from 60 centers (US, UK, Canada)
– Select population of enthusiastic, motivated, talented, intelligent,
energetic people asking for feedback of simulated settings
• 1 week course; small groups of 5 with facilitator
– Six 2-hour training sessions, simulated patients, etc
– Encounters discussed in working groups
• Feedback on feedback
– Qualitative (narratives) and quantitative (semantic differential
ratings of different techniques)
Hewson MG, Little M, J Gen Intern Med 1998;13:111-116

Critical Steps
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

Method of feedback

Method of feedback

Timing of feedback
• Ideally, schedule/prepare person for session
– e.g. at end of first week of rotation, quarterly, after
code or difficult procedure
– Clarify why you are giving feedback
– If delayed = “advice”
• Allow resident self-appraisal
• Defuse emotionally charged situation
• Immediate – constructive criticism
• Logical, practical (prevent recurrence; unique)
• Avoid emotionally charged situation

Critical Steps
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

Method of feedback

2. Elicitation
• Ask recipient about their goals
– “What are/were your goals for this rotation?
• Ask person for self-assessment
– “How do you think it went?”
– “What did you do well?”
– “What could be improved?”
– “How did it go for you?”

Critical Steps
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
• Content of the feedback
4. Improvement Plan
5. Application
6. Review

Content of feedback

Content of feedback

3. Focus on specific observations
• Sometimes forced to resort to “practical”
feedback (esp. if there’s a pattern)
– e.g. “There’s a perception by some of the
support staff that… When you go out into
practice, you cannot afford to be perceived
as…”

Content of feedback

Difficult
Easy
Job Skills Time and Work
Management
HELPING PEOPLE CHANGE: EASY TO DIFFICULT
Know ledge Attitude Habits Personality
Characteristics

3. Content of feedback
1. Based on your observations ideally
2. Based on specific actions
3. Based on behavior, not personality

Content of feedback

3. Steps to goal-based feedback
• You respond to the self-assessment
• And explain your responses in context of
shared goals

Method of feedback

4 Methods of Feedback
• Sit-Down One-on-One Feedback Model
– Feedback Sandwich or Oreo Cookie
• Feedback on the Fly Model
– Open-faced Sandwich

4 Methods of Feedback
• Start, Stop, Continue Model
– Start – What learner needs to start doing
– Stop – What learner needs to stop doing
– Continue – What learner should continue
doing
• Agenda Led, Outcome-based Analysis
– ALOBA model

Agenda Lead, Outcome-Based
Analysis – ALOBA model
• Self assessment by learner to acknowledge what was
done well
• What was done well reinforced by the teacher
• Skills used to achieve successful outcomes discussed
• Self-assessment by learner – what could have been done
better – analyses alternatives skills
• Facilitator suggests alternative skills if necessary
• Learner feedback to the facilitator - content of feedback
and skills

Critical Elements
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

Method of feedback

4. Improvement Plan
• Invite person’s suggestions
– “How do you think it could have gone
differently?”
• Ask again about goals
– “Have your goals changed?”
• Give your suggestions/Teach
– “This is my suggestion:”
• Consider identifying a coach

Critical Elements
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

5. Application
• Apply planned improvements/strategies to
current or future problems
– “What will you do next time?”

Critical Elements
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

6. Review
• Person reviews performance, behaviors,
including any that need change
– What do you do well?
– What changes will you make?
• Reaffirm person’s worth and ability to
correct their behavior
– “I am confident that you’ll be able to…”
• Schedule follow-up (when applicable)

Critical Elements
1. Orientation and Climate
2. Elicitation
3. Diagnosis and Feedback
4. Improvement Plan
5. Application
6. Review

Small Group Cases
• Work in pairs or trios
• Pick 2 cases
• Focus on the feedback language you
would use

Don’ts
1. Don’t email feedback (esp. negative)
• No opportunity for orientation, elicitation
• No opportunity to clarify the facts
• Impersonal
• No way to control tone or modify conversation
2. Try not to give feedback when angry
• Think about the timing of your feedback
3. Don’t be accusatory, demeaning or sarcastic
4. Avoid negative feedback in front of
peers/patients
5. Think about post call/up all night issues

Take Home Points
• Tell the person that you are going to give
them feedback
• Engage the learner in the process – self
assessment
• Focus on behaviors – what needs to be
changed
• Develop an action plan

• Hilary Sanfey
• Ted Burns
• Nancy McDaniel
• Casey White
Acknowledgements
• The patients, students, residents &
colleagues I have worked with over the
past 20 years.

Suggested Reading
• Sachdeva A. Use of effective feedback to facilitate adult
learning/ Journal of Cancer Education 1996;11:106-118
• Salermo et al. Faculty development seminars based on
the one minute preceptor improve feedback in the
ambulatory setting. JGIM 2002;17(10):779-787
• Spickard A. Words hard to say and hard to hear ”May I
give you some feedback?” JGIM 1998;13(2):142-143
• Hewson M et al. Giving feedback in medical education:
verification of recommended techniques. JGIM
1998;13(2): 111-116

Suggested Reading
• Gil et al. Perceptions of medical school faculty
members and students on clinical clerkship
feedback. J Med Educ. 1984; 59:856 – 864
• Irby et al. Factors affecting ratings of clinical
teachers by medical students and residents J
Med Educ 1987;55:1-7
• Isaacson JH et al Resident Perceptions of the
evaluation process. Society of General Internal
Medicine. J Gen Intern Med 1995;10(suppl):89