MedEd

Providing Feedback: An Effective Use of Teaching Time?

Michelle Elizov, MD

About the Author

Michelle Elizov is an assistant professor of medicine at McGill University. She is completing an MSc in Health Professions Education. She is the Jewish General Hospital site director of the Internal Medicine Residency Training Program. Her interests are medical education and eating disorders.

General internists are often at the heart of much of the teaching that goes on in our various practice settings. Through our frequent interactions with learners, we have come to recognize the importance of well-structured teaching as a means of effectively sharing our knowledge and skills. We also recognize that the provision of feedback is required as part of the teaching process. In fact, giving feedback is a crucial part of the learning process. Providing well-structured feedback, even informally, can enhance the learning experience, making it much more effective without necessarily taking up more time.

How many times have you heard students or residents complain that they didn’t get any feedback during an entire rotation? And how many times have you scratched your head and said to yourself, “Well, of course I gave him feedback!” Part of the problem with this all-too-common scenario is that, unless the learners hear the words “I am now going to give you some feedback,” they often do not recognize that they are getting constant feedback. This usually highlights the difference between summative and formative feedback.

Summative forms of feedback are, unfortunately, what tend to preoccupy our learners. This type of feedback is often given at the end of a rotation and indicates whether the learner has been successful. It is an evaluation that determines if the learner has met the predetermined expectations, such as the examination given at the end of the course that determines the final grade for that course.

Formative feedback is evaluation that is ongoing with the intent of providing the learners with information or guidance required for appropriate modification of their performance. The emphasis is on the provision of information rather than a judgment of performance. This is the day-to-day verbal commentary on such things as the presentation of a differential diagnosis or the successful insertion of a central line. Viewed in this way, it then becomes clear how this feedback is really just another form of teaching. When done in partnership with the learners, feedback promotes active learning.

Like the scenario described above, in many cases the learners are correct: no feedback or only superficial positive feedback is given. Why does this happen when feedback is clearly a powerful teaching tool? There may be concerns that the feedback will have effects beyond its intent, for both the teacher and the learners. The teacher may be afraid of hurting the learners’ feelings or crushing their enthusiasm, or may worry that providing “negative” feedback will damage the relationship with the learners, leading to decreased effectiveness of the teacher in the future. The learners may misconstrue the negative feedback as a personal commentary, rather than a comment on their performance. However, by avoiding giving proper feedback, we might create an environment where mistakes are not corrected; learning occurs by trial and error, and summative evaluations, such as written examinations, take on inflated importance as learners may feel that these are the only way to measure their abilities.

Given these concerns, how to give effective feedback becomes an increasingly important question. Some basic principles of providing feedback are outlined here. The “trick” is to apply these principles in the context of our busy lives, making it an automatic part of our teaching process, while remaining conscious of the subtleties of the language we use to express our observations.

The following detail what feedback should be.

1. Expected by the learners. This is easier to understand in the context of more formal feedback given halfway through a rotation, for example. But if we learn to give feedback regularly, it becomes expected and often even sought out by the learners, which further enhances the active learning process. Unexpected feedback, especially if it’s negative, will almost always be met with an emotional response.

2. Timely. Ideally, feedback should take place at the time of the observed event or soon thereafter while things are still fresh in your mind. This may not apply if emotions (the learner’s or yours) are running high; in this case, a “cooling off” period is needed, but keep notes of your observations of the event for future use.

3. Objective and specific. This is where language becomes so important. The feedback should be given on what you have observed, not second-hand information, and should address modifiable behaviours rather than subjective interpretations of intent or personality style. For example, to say, “I noticed you did not keep eye contact with the patient,” might be more useful than “You are too shy with patients.” Or, “You were late three times this week for teaching rounds” might be more helpful than “Your organizational skills need to be improved.”

4. Regulated. Giving too much information at one time will overwhelm the learners, who will then disregard everything rather than try to sift through and pull out the two or three things felt to be most important. Equally undesirable would be that the learners pull out the points they feel are most pertinent, not the ones you believe are most important. The learners may also pay attention only to points that confirm their own impressions, which may not be accurate.

5. Balanced. Giving negatives without positives may seriously undermine the learners’ confidence; but, positives without negatives may lead to overconfidence and the pitfalls inherent to that. Frequent superficial positive praise, such as “You’re excellent!” may lead to the implication that the people, not their work, are being assessed.

6. Given in a nonjudgmental manner. If you say, “That differential diagnosis was completely inadequate,” your learner will shut down and not really hear anything further, no matter how valid the teaching point. It may be more helpful to say, “Your differential diagnosis included only three items, one of which is highly unlikely, and did not include these common problems …”

7. An opportunity for self-reflection and development of alternatives. Using open-ended questions such as: “What do you think went well?” “Where do you think you can improve?” or “How do you think you can do that differently next time?” encourages active learning, where the learners participate in identifying strengths and deficiencies and in the development of learning strategies in the context of their own previous experiences and perspectives. The advantage of this is that the learners will be able to better integrate the new information into their own conceptual frameworks, which will make it easier to use again in future situations.

8. Structured. Like any good teaching method, there is a beginning (“Let’s go over how that line insertion went”), a middle, where the observed behaviours are discussed (“I noticed that you …”), and an end, where a plan of further action is developed with the learners and preferably by the learners themselves (“Next time, I think I’ll try …”). Ideally there would also be a follow-up, where you have an opportunity to observe a similar clinical scenario again and can link the previous feedback to the current situation.

Conclusion

While trying to incorporate all the above points and concepts may seem daunting in the 3 minutes you may have between cases, it is important to realize that providing feedback effectively is, like much of what we do in medicine, a learnable skill. It will initially take a very conscious effort to recognize the opportunities in your interactions to provide feedback and then to structure it and deliver it in a format that will be well received and useful. However, as you repeatedly engage in this teaching moment, you will find that the process becomes more fluent, more automatic, and hence faster, all the while retaining its purpose, which is to help us help our learners become better doctors.

Bibliography

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Article Citation: Elizov M. Providing feedback:An effective use of teaching time? Can J Gen Intern Med 2007;2(3):24-25