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Learning to give feedback in medical education

Authors:

Abstract

Giving feedback is an essential part of medical education but it is a responsibility that teachers often avoid. Constructive feedback is a generic skill that can be learned. In this article we highlight various methods of giving this constructive feedback.
EDUCATION
The Obstetrician
& Gynaecologist
2004;6:243–247
Keywords
ALOBA technique,
giving feedback,
medical education,
Pendleton’s rules
© 2004 Royal College of Obstetricians and Gynaecologists 243
© 2004 Royal College of Obstetricians and Gynaecologists
Introduction
Undergraduate and postgraduate students often
receive feedback that leaves them feeling
bruised, demoralised 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’. Hewson
et al.1describe how, in faculty development
courses, clinical teachers frequently indicate that
their greatest need is to learn how to give
feedback effectively. This difficulty in giving
feedback may be based on reluctance to give
offence or provoke undue defensiveness.2
What is feedback and is it
necessary?
Rocket engineers developed the concept of
feedback in the 1940s where the system used
information to reach its goal.2
Most people have a basic need to know how
well they are doing, as the expectation of success
is fundamental to motivation and effort.3Both
increase when we expect to succeed but decrease
or cease when the goal is perceived as almost
certain or impossible.4
Effective feedback occurs when the trainees are
offered insight into their actions and the conse-
quences thereof. Such insight is valuable because
it highlights the difference between the intended
and the actual result, and provides an impetus for
change.5
Feedback, therefore, drives learning and progress
and is essential in allowing a student to remain
on course in reaching a goal. On the teacher’s
part, it also conveys an attitude of concern for
the progress and development of the person in a
real sense and not just as a function of grades or
test scores.2If handled incorrectly, it may damage
the student–teacher relationship and inhibit giv-
ing or receiving feedback in the future. In such
situations, the student may view feedback as a
statement about his or her personal worth or
potential, whereas in reality feedback presents
information, not judgement.6
Guidelines for giving feedback
The process of feedback is informed; non-
evaluative, objective appraisal of performance. It
is intended to improve skills or change behav-
iour, rather than being an estimate of the
students’ worth.
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. Teachers are
often not able to clearly distinguish between
non-evaluative and evaluative feedback, more
commonly termed feedback and summative
assessment. For example, if a house officer finds
it difficult to prioritise a patient’s symptoms,
making him aware of this deficit and working
out a definite plan on how to correct it consti-
tutes non-evaluative feedback. Summative
assessment, on the other hand, tells the learner
how they performed:“You have corrected your
problems” or “You need to continue working
on it”.This should follow feedback.
Ende et al.7have produced guidelines for con-
structive feedback in medical education, which
have their origins in personnel management,4,8
group dynamics9and education.10 These are
shown in Box 1.
How to phrase feedback
Based on Ende’s principles, feedback should be
descriptive and non-judgemental. Phrasing feed-
back as “That was awful” will always create
defensiveness. A descr iption of what happened
might be more helpful, such as: “When she was
telling you about her stomach pains, I noticed
that you were concentrating on the GP’s letter,
Learning to give feedback
in medical education
Rahul Roy Chowdhury and Gregory Kalu
Giving feedback is an essential part of medical education but it is a
responsibility that teachers often avoid. Constructive feedback is a
generic skill that can be learned. In this article we highlight various
methods of giving this constructive feedback.
Author details
Rahul Roy Chowdhury MRCOG,
Senior Trust Grade Doctor,
Department of Obstetrics and
Gynaecology, Brighton and Sussex
University Hospitals NHS Trust,
Princess Royal Hospital, Lewes
Road, Haywards Heath, RH16 4EX,
UK. email: rroychowdh@aol.com
(corresponding author)
Gregory Kalu MRCOG LLM,
Consultant, Brighton and Sussex
University Hospitals NHS Trust,
Haywards Heath, UK.
10.1576/toag.6.4.243.27023 www.rcog.org.uk/togonline
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which prevented eye contact between you”.This
is non-judgemental, descriptive feedback.
Non-specific praise such as “You appeared
empathic”, without a descr iption of the episode
being referred to,is of no use. It is better to point
out a specific behaviour; for instance,“Your facial
expression changed when you were listening to
the woman’s story, which highlighted that you
were empathising with her”, helps the learner to
look at the skills they used to express empathy
and at the concept of empathy itself.
Feedback should describe behaviour, which can
be changed, rather than personality. The process
should help the learner and not provide a plat-
form for the facilitator to promote their knowl-
edge, superiority or power. It should also be
about sharing information. Feedback is not a
prescription for change. Changes that need to be
made ought to be decided by the learner, thus
allowing them to preserve their self-esteem. It
may even be useful to encourage the student to
undertake an assessment of their own perform-
ance and suggest remedial measures, as this often
brings up the points that the teacher is trying to
make and reduces the perceived harshness of the
feedback, especially when it involves sensitive
topics. Sometimes the student may raise issues
not thought of by the teacher, which then need
to be addressed.This makes the process of feed-
back interactive.
It is important to check that the learner under-
stands the content of the feedback.The learner
should be encouraged to check this by reiterat-
ing the contents to the facilitator.This prevents
misunderstanding and distortion of feedback.
The feedback given should be limited to the
amount of information that can be dealt with
comfortably; excessive volumes of feedback may
overwhelm the learner and prevent any changes
from taking place. It should be a part of the
learning contract between the learner and the
facilitator; it should be solicited rather than
imposed and given privately.
There is evidence that these principles and tech-
niques work. Using both qualitative and quantita-
tive approaches, Hewson and Little1showed that,
when recommended techniques of feedback were
used, recipients found the experience helpful.
Feedback is more useful when it relates to a behav-
iour that can be changed rather than to something
that cannot be changed. Many respondents men-
tioned that the feedback was helpful, even correc-
tive feedback, if the recommended techniques
were used. However, one respondent described an
unhelpful feedback episode that consisted of non-
specific praise, thus substantiating the importance
of giving specific feedback based upon observa-
tions, even when these are favourable.
Unhelpful feedback
It has long been recognised that certain
approaches to feedback may be counterproduc-
tive. Hewson and Little1highlight some of these.
When a feedback episode did not elicit a learner’s
ideas, feelings or goals, it failed. For example, one
respondent commented:“feedback was based on
goals that were different from mine”. It also failed
when learners felt slighted, demoralised, blamed
or rejected. Similarly, feedback conveying per-
sonal judgements was poorly received; for exam-
ple, “You are obsessive–compulsive”, “You are
narrow minded”; as were insults such as “Doctors
ought to shut up”. Lectures or information that
was regarded as redundant or gratuitous led to
failure of feedback, as did giving feedback in
inappropriate places.
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Box 1. Feedback
Feedback should be:
undertaken with the teacher and the trainee working as allies towards a
common goal
expected
at a mutually agreed time and place
close in time to the episode on which it is sought
based on specific behaviour rather than general performance and should
have been ideally observed at first hand
given in small quantities and limited to remediable behaviours
descriptive, non-evaluative and non-judgemental
composed of subjective data, which should be labelled as such
given on decisions and actions and not on one’s interpretation of the
student’s motives.
[Adapted, with permission, from Ende2]
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Using a SET-GO method of giving
feedback
By making feedback descriptive, it becomes non-
judgemental, specific and directed towards behav-
iour.When the group or facilitator reflects back
to the learner what they saw, it helps the learner
to acknowledge the incident and reflect on it and
find a solution to the problem. The description
also provides information on the effect the inci-
dent had, which allows the learner to consider
the desired outcome and the skills necessary to
achieve it. This underpins the ‘agenda-led,
outcome-based’ feedback method, discussed
below.
SET-GO11 is an aide memoire for the sequence of
actions when giving descriptive feedback, and is
shown in Box 2.
Models of giving feedback
The two most widely accepted models of giving
feedback are adapted from the world of educa-
tion. In medical education, Pendleton’s rules are
used as the conventional method of feedback.12
An alternative approach, devised by Silver man, is
known as agenda-led, outcome-based analysis or
ALOBA.13 They are similar in that they provide
a safe environment for the learner,thus reducing
defensiveness and making the experience con-
structive. Both methods are suitable for use in
either a group or a one-to-one situation.
Pendleton’s rules (Figure 1) 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 fol-
lowed by the facilitator or group reinforcing these
positives and discussing skills to achieve them.
“What could be done differently?” is then sug-
gested, first by the learner and then by the person
or group giving feedback. The advantage of this
method is that the learner’s strengths are discussed
first. Avoiding a discussion of weaknesses r ight at
the beginning prevents defensiveness and allows
reflective behaviour in the learner.
There are some deficiencies14 in the rules.They
create artificiality and rigidity by forcing a dis-
cussion of the learner’s strengths first. Thus, an
opportunity for an interactive discussion of top-
ics that might be relevant to the learner is lost.
There is also inefficient use of time because the
same topic is discussed twice in its entirety: first
to discuss the strengths and then the weaknesses.
To someone expecting primar ily negative feed-
back, the discussion of strengths may appear
patronising, which makes the feedback more
stressful and, perversely, a disproportionate
amount of time may be spent discussing
strengths to soften the impact of the negatives.A
judgemental tone may also creep into the feed-
back when “What was done correctly and what
was incorrect?” is discussed, which goes against
the non-evaluative and for mative nature of
feedback.
Silverman tried to offset the disadvantages of
Pendleton’s rules by devising the ALOBA
approach (Figure 2).13 In this method, the
principle is to identify what the learner wants
help with. The discussion is then directed
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Box 2. SET-GO
What I Saw – Describing what I saw.
What Else did you see? What happened next.
What do you Think? Reflect back to the learner.
What Goals are we trying to achieve?
Any Offers on how to achieve the goals – suggestions regarding skills and
rehearsals.
Figure 1. Pendleton’s rules
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towards achieving the learner’s goal by encou
aging self-assessment and by opportunistically
introducing the facilitator’s agenda and
discussion of new theories and concepts. This
empowers the learner and reduces defensive-
ness, while allowing an opportunity for change
in behaviour.
At the outset, the learner identifies the agenda
and what they want help with. This early
acknowledgement of difficulties removes defen-
siveness and allows the learner to concentrate on
the feedback itself rather than being anxious about
the nature of the negative feedback. In the next
step, the facilitator tries to ascertain the outcome
that the learner is trying to achieve.The discussion
then concentrates on the skills necessary to achieve
these outcomes and removes the judgemental
(what was done well and what could have been
better) and moral slant to the advice given. The
process focuses on trying to achieve a desired out-
come by using a set of skills, rather than criticising
the learner about what was done wrongly.This sig-
nifies the true philosophy of feedback.
This is followed by self-assessment and self-
problem-solving. This ensures that the learner is
actively involved and is not merely a passive recip-
ient of advice. Either the group or the facilitator
feeds back to the learner (using the SET-GO pr in-
ciple), which enables the learner to acknowledge
and reflect on the advice given and to identify the
skills required to achieve the desired outcome.
Continuing to keep the focus on achieving the
desired outcome, the group or facilitator
explores alternative skills to try and reach the
goal, rather than criticise the learner for their
failures. As in the earlier example of the house
officer unable to prioritise urgent symptoms,the
facilitator or group works with the learner to
find alternative ways of achieving their goals,
rather than criticising the learner. This process
should be descriptive, non-judgemental and per-
taining to behaviour that is amenable to change.
The suggestions generated can then be rehearsed
to see whether they work.Experimentation may
be undertaken in the safety of rehearsals and
necessary changes in skills can be practised.
It is important that a balance is maintained while
giving feedback.This is made simple in Pendleton’s
rules by the ‘good’ preceding the ‘bad’. In ALOBA,
the responsibility and judgement lie with the facil-
itator,and it is possible that an inexperienced facil-
itator may achieve the wrong balance. This may
have a negative impact on the learner’s experience
of feedback.Thus, Pendleton’s rules may be a safer
alternative for inexperienced facilitators.
The other principle of ALOBA is to present a
supportive environment by making offers and
suggestions and giving alternatives. The exercise
is interactive and becomes a learning opportu-
nity for all. Everyone involved is an equal partic-
ipant and contributor to the activity. In contrast,
in Pendleton’s method the learner is a passive
recipient of suggestions from the facilitator or
group – everyone makes suggestions to change
the learner’s behaviour.
This learning context allows the facilitator to
introduce new concepts, research evidence and
various principles of communication, and clarify
specific skills through demonstration and discus-
sion. In Pendleton’s rules, this is not specified but
can be undertaken by a skilful facilitator when
they or the group are making suggestions for
“What could have been done differently?”.
Once the exercise has been completed,the entire
session should be summarised into a concise
format; the skills necessary to achieve a particu-
lar outcome should be highlighted and an over-
all conceptual framework built.
A critical analysis of Pendleton’s
rules and the ALOBA technique
of feedback
Pendleton’s approach has been criticised for its
rigidity, the attachment of a moral slant to its
advice and for not actively involving the learner
in reaching their goal.14 The ALOBA technique
tries to rectify these shortcomings. A close
246
Figure 2. ALOBA principles
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examination of ALOBA shows that, despite the
focus being on achieving a particular goal, there
is, nevertheless, a covert element of judgement
attached to it. Ende2clarifies this by saying,
‘Actually, there is almost always a judgement
assigned to feedback information. Somehow, on
the wards, positive feedback sounds good, while
negative feedback sounds bad.There is simply no
way you can inform a student that a differential
diagnosis did not include the most likely disease
without causing some disappointment or embar-
rassment.This does not mean that you shouldn’t
bring such information to the student’s attention
but, rather,that it should be done with some skill
and understanding of the process’.The inflexibil-
ity of Pendleton’s rules is apparent in the fact that
good always precedes bad.This may lead to a dis-
proportionate allocation of feedback time
because of discussion of issues not important to
the learner. In his defence, Pendleton has argued
that his ‘rules’ are only guidelines and not dik-
tats.15 By continuing to follow the format of
always discussing which goals were fulfilled, in
the beginning, a better understanding of why
certain tasks were achieved can be ascertained
and subsequently reproduced at will.This helps
to build the skill base. Also, maintaining a posi-
tive tone of feedback, both for achievements and
for what could be done differently, helps to pre-
serve and enhance the learner’s self-esteem.
Some other models of giving
feedback
Some other models of giving feedback have been
discussed elsewhere.16 These include the ‘A five
step microskills model of clinical teaching’,17 the
SCOPME model,18 the Chicago Model19 and
the six-step problem-solving model.16 All these
are adaptations of Pendleton’s rules and the
ALOBA technique.
Conclusion
Giving feedback, whether corrective or rein-
forcing, is an essential part of medical education,
which helps to promote learning and ensures
that standards are met. Unfortunately, it is also a
difficult part of clinical teaching and trainers
often avoid this aspect of their responsibilities.2
Given correctly, constructive feedback can
improve learning outcomes and enable students
to develop an analytical approach to learning. It
can also improve competence, at least in the
short-term.20 A review in 1998 showed that con-
structive feedback produced significantly better
learning outcomes in a wide variety of learning
situations.21 Knowles showed that adult learners
welcome feedback when it is based on their per-
formance and tailored to their goals.22
Giving feedback constructively is a generic skill
that can be learned. It can be used in the context
of formal educational supervision as well as in day-
to-day situations with colleagues,staff and patients.
Ultimately, feedback is about communication.
The key skills are to listen and ask, not to tell
and provide solutions.4It is a skill that is not as
rare as it used to be but there are still not
enough trainers who understand the underly-
ing principles of feedback in the modern clini-
cal setting. 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.
247
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... 7 Historically, feedback in medical education has ignored the importance of students participating in the discussion to concentrate primarily on how well teachers can deliver feedback to students. 8 According to Chowdhury and Kalu,9 students could obtain insightful feedback if they established a comprehensive awareness of the activities and outcomes they had previously taken. Providing feedback to students is an essential part of their educational process. ...
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Background Feedback is defined as the regular mechanism where the effect of an action is to modify and improve the future action. Feedback is essential for developing students’ competencies and their future work as professionals. The attention of feedback shifted from teachers’ feedback techniques to learners’ goals, acceptance, and assimilation of feedback and impact-focused approaches. This study explored the perceptions of medical students and faculty regarding the importance of constructive feedback and the process of feedback in medical education. Methods An explanatory, sequential, mixed-method approach was used, beginning with a survey followed by interviews. This study was conducted at Defense Services Medical Academy (DSMA), Myanmar, and Avalon University School of Medicine (AUSOM), Willemstad, Curacao, from November 2021 to October 2022. For the quantitative phase, 75 students of Phase I, M.B.B.S. program, 28 faculty from DSMA. 63 students of the M.D. program, and 13 faculty from AUSOM responded to the questionnaire survey. For the qualitative phase, ten students and ten faculty members from each university used in-depth interviews. We used MAXQDA software for thematic analysis. Findings Survey results showed that most faculty and students strongly agree that feedback is essential for students’ learning and should highlight both strengths and weaknesses of student performance. Thematic analysis resulted in five themes: opinions regarding the feedback, obstacles in obtaining constructive feedback, incorporating constructive feedback to future professions, implementing feedback, and comparing the views of students and professors. The students wanted immediate feedback after the examinations. They preferred one-to-one feedback instead of group feedback, but the faculty was concerned about time limitations in providing constructive one-to-one feedback. Conclusion The students and faculty agree that constructive feedback is essential to improve performance. The students at both institutes preferred precise comments regarding performance. The barrier both faculty and students faced around giving and receiving feedback was time.
... A 2012 report by the Association of American Medical Colleges showed that up to one-third of medical student respondents felt they did not receive adequate feedback on their performance during the core clerkships. 1 Research has shown that an important aspect of effective feedback is the timeliness of its delivery. 2 Timely feedback grounds learners in the recent experience, links feedback to specific observations, and draws clear connections between the feedback and its future applications. A videotape analysis by Maguire and Rutter 3 of histories obtained by 50 medical students revealed significant deficiencies in their history-taking skills. ...
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Purpose Coaching is a well-described means of providing real-time, actionable feedback to learners. We aimed to determine whether dual coaching from faculty physicians and real inpatients led to an improvement in history-taking skills of clerkship medical students. Patients and Methods Expert faculty physicians (on Zoom) directly observed 13 clerkship medical students as they obtained a history from 26 real, hospitalized inpatients (in person), after which students received immediate feedback from both the physician and the patient. De-identified audio-video recordings of all interviews were scored by independent judges using a previously validated clinical rating tool to assess for improvement in history-taking skills between the two interviews. Finally, all participants completed a survey with Likert scale questions and free-text prompts. Results Students’ history-taking skills – specifically in the domains of communication, medical knowledge and professional conduct – on the validated rating tool, as evaluated by the independent judges, did not significantly improve between their first and second patient interviews. However, students rated the dual coaching as overwhelmingly positive (average score of 1.43, with 1 being Excellent and 5 being Poor), with many appreciating the specificity and timeliness of the feedback. Patients also rated the experience very highly (average score of 1.23, with 1 being Excellent and 5 being Poor), noting that they gained new insights into medical training. Conclusion Students value receiving immediate and specific feedback and real patients enjoy participating in the feedback process. Dual physician-patient coaching is a unique way to incorporate more direct observation into undergraduate medical education curricula.
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... Written assessments are vital in education as they measure students' capacity to attain learning objectives and bridge the gap between teaching and understanding [1]. In addition to providing feedback on students' performance, such assessment allows evidence-based monitoring of students' progress and learning outcomes [2]. ...
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... Hewson describes how teachers in faculty development courses often indicate that their greatest need is learning how to provide effective clinical feedback. This difficulty in providing feedback may be because of an unwillingness to offend or to provoke undue defensiveness [5]. The Feedback Quality Instrument's validity and reliability are crucial for ensuring the accuracy and usefulness of feedback provided to trainees ...
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Background The purpose was to investigate the psychometric features of the Feedback Quality Instrument (FQI) in medical students, emphasizing the instrument’s utility for evaluating the quality of feedback provided in clinical contexts and the importance of performing so for medical trainees. Methods and material The Persian version of the FQI was evaluated for content validity through a focus group of medical education experts. The questionnaire’s face, content, and construct validity were assessed using Confirmatory Factor Analysis, internal consistency, and inter-rater reliability. The questionnaire was revised and pilot-tested, with medical students’ feedback in different clinical situations. The data was analyzed using AMOS26. Results The content validity index equaled 0.88(> 0.79). The content validity ratio representing the proportion of participants who agreed on a selected item was 0.69(> 0.42). According to experts, item 25 is the only modified item, while items 23 and 24 are presented as one item. For reliability, Cronbach alpha was equaled to 0.98. Conclusions The Persian version of the Feedback Quality Instrument (FQI) was valid, reliable, and fair in assessing feedback quality in medical students, providing valuable insights for other institutions. Establishing a basis for systematically analyzing how certain educator behaviors affect student outcomes is practical.
... Quatrièmement, la préceptrice et l'IND discutent des options qui s'offrent à elles pour atteindre les objectifs ciblés et elles développent ensemble un plan d'action (Chowdhury et Kalu, 2004). Finalement, la cinquième et dernière étape consiste à clore la discussion de rétroaction. ...
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https://www.oiiq.org/en/la-maladie-de-parkinson-le-traitement-en-mouvement
... However, most of the studies conducted on the power of feedback in formative assessment have been done using Rienits 10.3389/fmed.2024.1395466 experienced clinicians or professionals to provide the feedback to the trainee (7,9). More studies are needed on the efficacy of feedback provided by peers, especially reciprocal peers. ...
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Providing feedback is central to training doctors. Jennifer King considers theoretical and practical aspects of this important skill for all who teach or appraise “I shall always be a flower girl to Professor Higgins because he always treats me as a flower girl … But I know I can be a lady to you because you always treat me as a lady, and always will …”1 Consultants and general practitioner trainers play Pygmalion-like roles in developing able trainee doctors and stimulating their performance. Some consultants and trainers treat their junior staff in a way that leads to superior performance. Others, like Professor Higgins, unintentionally treat their trainees in a way that undermines their efforts and fails to develop their potential as doctors. There is a growing body of evidence that demonstrates the power of positive expectations - the so called Pygmalion effect.2 Trainees are hungry for regular and constructive feedback,3,4 but one of the commonest concerns of educational supervisors is their ability to “give effective feedback, both praise and constructive criticism.”5 Despite feedback being an integral part of training it is an area for which many consultants and general practitioner trainers feel ill prepared.6 This led us to develop a tailored training programme in appraisal skills and constructive feedback to bring out the best in trainee doctors. The two questions most often asked by consultants on our course are how to keep trainees motivated and how to give difficult feedback constructively. Feedback and motivation Most people have a basic need to know how well they are doing; and the expectation of success is fundamental to motivation and effort.7 Both increase when we expect to succeed but decrease or cease when the goal is perceived as almost certain or impossible. Similarly, behaviour theory suggests that positive reinforcement of a specific behaviour increases the chances that the behaviour will be repeated. So as the trainee performs, the trainer should select specific aspects of the performance for praise and highlight these to the trainee. Unfortunately, what tends to happen is that only the poor aspects are identified. This may have the desired effect of reducing future occurrences of this behaviour, but it also produces the undesirable effect of increasing anxiety, even fear, and reduces the trainee's openness to further learning and evaluation. Factors that affect motivation in tasks 8 People are motivated when they are: Clear about what is expectedSupported by managers or supervisorsRecognised for their effortsContributing in a way which is positive and recognisableFree to express their views and ideasChallenged in a way which helps them to develop and be more creative Here is the nub of the feedback challenge: how to draw trainees' attention to their less satisfactory aspects while maintaining or even increasing their desire to learn, improve, and seek further evaluation. Psychological research shows that six factors have a significant effect on job involvement, effort, and, ultimately, productivity (see box).8 These factors contribute to a positive psychological climate at work. All these factors are embodied in, and facilitated by, effective feedback. Criteria for feedback People are motivated when they are: Descriptive - of the behaviour rather than the personalitySpecific - rather than generalSensitive - to the needs of the receiver as well as the giverDirected - towards behaviour that can be changed (“You're too tall” is unhelpful)Timely - given as close to the event as possible (taking account of the personõs readiness, etc)Selective - addressing one or two key issues rather than too many at once Making it effective Effective feedback requires a combination of qualities, skills, and some structure. We routinely ask consultants and trainees to describe their own experiences of receiving feedback and to identify the characteristics that made it a positive or negative experience. The most commonly cited positive features include mutual respect, specific praise or criticism, a genuine desire to help, and allowing time. Negative features typically include public humiliation, comments on personality, no opportunity for a two way discussion, lack of personal interest, too general, and too little too late. Some argue that their most formative experiences were the result of very negative feedback and that providing constructive feedback smacks of “mollycoddling.” In the face of increasing stress, diminishing morale, and recruitment crises these arguments are hard to sustain. And challenge and support are not opposite ends of a spectrum: challenge alone provides a potentially punitive environment; support alone does not push people to develop. Athletics coaches and good managers know that they can boost a person's performance by giving them a suitable challenge combined with an expression of confidence. When the challenge increases, so must the support. This is a key principle for effective feedback. Skills of effective feedback Ultimately, feedback is about communication. The skills are generic: active listening; asking a balance of open, reflective, facilitating, and closed questions; challenging; and summarising. Giving feedback is not just to provide a judgment or evaluation. It is to provide insight. Without insight into their own strengths and limitations, trainees cannot progress or resolve difficulties. Thus, the key skills are to listen and ask, not, as is often the temptation, to tell and provide solutions. Compare ineffective and effective feedback: “You need to sort out your bleep — you're impossible to contact.” with “Tell me more about the problems you experience when you are on-call” Similar skills apply when giving positive feedback. Speaking in generalities (“You seem to be progressing well”) is not as helpful as giving specific examples: “You are particularly good at giving bad news to relatives. You take your time, and listen well to their concerns.” Structure for feedback Another common difficulty is structuring a feedback discussion. In the early 1980s a method was developed to help doctors to develop their consultation skills.9 This method is invaluable for any feedback discussion, formal or informal: The trainee is asked to start by identifying his or her own strengthsThe trainer reinforces these and adds further strengthsThe trainee is asked to identify areas for improvementThe trainer reinforces these, adding further areas if necessary. The pitfall is to be pressurised to start at stage 4 to “get the worst over with.” This immediately puts the trainee on the defensive and potentially negates any subsequent positive feedback. The structure works on the simple principle of an emotional bank balance - withdrawals cannot be sustained without credits in place first. It also embodies, once again, that crucial balance of support and challenge. It does not allow either party to downplay strengths or to duck difficult issues. It is a model that is tried and tested in general practice training and with consultants in educational supervisor roles. Defensive reactions to feedback Person receiving feedback Blaming - “It's not my fault. What can you expect when the patient won't listen?”Denial - “I can't see any problem with that”Rationalisation - “I've had a particularly bad week” “Doesn't everyone do this?”Anger - “I've had enough of this” Person giving feedback Obligation - “I'm duty-bound to tell you this”Moral high ground - “It's for your own good”Burying and fudging - Taking a long time to get to the point and covering many irrelevanciesMinimising - “Don't worry, it's not such a big deal. Everyone does it at some time”Colluding - “You're probably right, perhaps I am overreacting” Reactions to feedback The skills and structure described here are designed to minimise adverse reactions to feedback and ensure that the experience is constructive. Nevertheless, a variety of defensive reactions can occur, and it is important to learn some strategies for dealing with them. It is not only the receiver of feedback who can become defensive: the person giving the feedback can also manifest similar reactions. Trying to tear down defences is not constructive - they are there for a reason. There are various strategies for reducing or eliminating defensiveness. The effective approach is the four stage, structured feedback described above. But if defensiveness persists or suddenly occurs the following approaches are useful: Name and explore the resistance - “You seem bothered by this. Help me understand whyKeep the focus positive - “Let's recap your strengths and see if we can build on any of these to help address this problem”Try to convince the trainee to own one part of the problem - “So you would accept that on that occasion you did lose your temper”Negotiate - “I can help you with this issue, but first I need you to commit to …”Allow time out - “Do you need some time to think about this?”Allow time out - “Do you need some time to think about this?”Keep the responsibility where it belongs - “What will you do to address this?” Feedback skills training Our experiences with trainers and trainees have shown clearly the merits of some specific approaches to feedback training. The most effective elements have been Involving real volunteer junior doctorsUsing video recording to reinforce the skills practiceModelling the feedback skills and structure during the practice sessions Wider applications Feedback skills are generic. They can be used not only in the context of formal educational supervision, but daily with colleagues and staff, in committee and departmental meetings, and in all training situations. Education must be learner centred, and feedback is at the core of this process. If educational supervisors can adopt some of these principles and skills, then perhaps Pygmalion will no longer be a mythical character. References↵George Bernard Shaw. Pygmalion. London: Addison Wesley Longman Education, 1991.↵Goleman D. Working with emotional intelligence. London: Bloomsbury, 1998.↵Riley W. Appraising appraisal [career focus]. BMJ 1998; 316(classified section 21 Nov):2–3 http://classified.bmj.com/careerfocus/7170cf.htm↵Firth-Cozens J, Moss F. Hours, sleep, teamwork, and stress. BMJ 1998; 317: 1335–6↵Cottrell D. Supervision. Advances in Psychiatric Treatment 1999; 5: 83–8↵Pencheon D. Development of generic skills[career focus]. BMJ 1998; 317(classified section 12 Sep):2–3 http://classified.bmj.com/careerfocus/7160cf.htm↵Atkinson JW. Motivational determinants of risk taking behaviour. Psychol Rev 1957; 64: 365↵Brown S, Leigh S. A new look at the psychological climate and its relationship to job involvement, effort and performance. Journal of Applied Psychology 1996; 81: 358–68↵Pendleton D, Schofield T, Havelock P, Tate P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press, 1984.
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We investigated naturally occurring feedback incidents to substantiate literature-based recommended techniques for giving feedback effectively. A faculty development course for improving the teaching of the medical interview, with opportunities for participants to receive feedback. Seventy-four course participants (clinician-educators from a wide range of medical disciplines, and several behavioral scientists). We used qualitative and quantitative approaches. Participants provided narratives of helpful and unhelpful incidents experienced during the course and then rated their own narratives using a semantic-differential survey. We found strong agreement between the two approaches, and congruence between our data and the recommended literature. Giving feedback effectively includes: establishing an appropriate interpersonal climate; using an appropriate location; establishing mutually agreed upon goals; eliciting the learner's thoughts and feelings; reflecting on observed behaviors; being nonjudgmental; relating feedback to specific behaviors; offering the right amount of feedback; and offering suggestions for improvement. Feedback techniques experienced by respondents substantiate the literature-based recommendations, and corrective feedback is regarded as helpful when delivered appropriately. A model for providing feedback is offered.