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Feedback, the various tasks of the doctor, and the
feedforward alternative
Avraham N Kluger
1
& Dina Van Dijk
2
OBJECTIVES This study aims to alert users of
feedback to its dangers, explain some of its
complexities and offer the feedforward alter-
native.
METHODS We review the damage that
feedback may cause to both motivation and
performance. We provide an initial solution to
the puzzle of the feedback sign (positive versus
negative) using the concepts of promotion focus
and prevention focus. We discuss additional
open questions pertaining to feedback sign and
consider implications for health care systems.
RESULTS Feedback that threatens the self is
likely to debilitate recipients and, on average,
positive and negative feedback are similar in
their effects on performance. Positive feedback
contributes to motivation and performance
under promotion focus, but the same is true for
negative feedback under prevention focus. We
offer an alternative to feedback – the feedfor-
ward interview – and describe a brief protocol
and suggestions on how it might be used in
medical education.
CONCLUSIONS Feedback is a double-edged
sword; its effective application includes careful
consideration of regulatory focus and of threats
to the self. Feedforward may be a good sub-
stitute for feedback in many settings.
cross-cutting edge
Medical Education 2010: 44: 1166–1174
doi:10.1111/j.1365-2923.2010.03849.x
1
Department of Management, School of Business Administration,
Hebrew University of Jerusalem, Jerusalem, Israel
2
Department of Health Systems Management, Faculty of
Management, Ben-Gurion University of the Negev, Beer Sheva,
Israel
Correspondence: Professor Avraham Kluger, School of Business
Administration, Hebrew University of Jerusalem, Mount Scopus,
Jerusalem 91905, Israel. Tel: 00 972 2 588 1009;
Fax: 00 972 2 588 1341; E-mail: avik@savion.huji.ac.il
1166 ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174
INTRODUCTION
Feedback interventions (FIs), which provide people
with information regarding their task performance,
are one of the most widely applied psychological
interventions. Some FIs are formal and some are less
so. Examples of formal FIs include grades in school,
teaching evaluations at universities, performance
appraisals in the workplace, and customer satisfaction
surveys in marketing departments. In parallel, teach-
ers, educators, supervisors and doctors routinely
provide information regarding conduct, abilities and
achievements to their students, subordinates and
clients. These practices beg the question of whether
or not FIs improve performance.
The typical answer to this question during the 20th
century was affirmative. This was the received wisdom
from the inception of research into this question in
1905
1
until the mid-1990s. For example, in the field of
industrial and organisational psychology, it was
believed that ‘the positive effect of FI on performance
has become one of the most accepted principles in
psychology’.
2
However, a comprehensive meta-analysis
of largely laboratory experiments cast serious doubt on
this conclusion.
1
This meta-analysis suggested that,
although FIs improve performance by 0.4 of a standard
deviation on average, FIs reduce performance in over a
third of the experiments. In searching for the moder-
ators (the conditions that make feedback more or less
effective), the authors found, among other things, that
the more threatening the feedback to the self (e.g. ‘the
task on which you will receive feedback predicts how
well you will do in the rest of your career’), the more
likely it is to debilitate performance. Surprisingly,
however, the threat to self does not stem merely from
failure. Specifically, Kluger and DeNisi
1
found no
evidence that FI effects are moderated by FI sign. That
is, negative FIs (information about failure) and positive
FIs (information about success) do not differ, on
average, in their effects on performance.
1
In summary,
the meta-analysis suggests that FIs can impair perfor-
mance and that the processes through which FIs affect
performance require better explanation. In this paper,
we present a better explanation for one keyfeature of FIs
– the feedback sign – and offer one alternative to
feedback – the feedforward interview
3
–thatmay
achieve the goals of the FI without threatening the self.
THE FEEDBACK SIGN
In an effort to solve the puzzle of the feedback sign,
Van Dijk and Kluger
4,5
suggested that the effects of
feedback sign on motivation depend on both the
chronic and the situational regulatory focus.
6
According to Higgins’ self-regulation theory,
6,7
people have two regulatory foci: prevention (a state of
mind characterised by vigilance and concern with
punishment), and promotion (a state of mind
characterised by eagerness and concern with
rewards). We predicted and found that when
prevention regulatory focus is activated (e.g. by
asking people to imagine working in a job because
they have to), negative feedback motivates participants
more than positive feedback (e.g. they report that
they will invest more effort in their job), whereas
when promotion regulatory focus is activated (e.g. by
asking people to imagine working in a job because
they want to), positive feedback motivates participants
more than negative. Before detailing the combined
effect of regulatory focus and feedback sign on
motivation and performance, we briefly elaborate on
the difference between prevention focus and pro-
motion focus by drawing on self-regulation theory.
Self-regulation theory
Higgins
6,7
noted that the idea that people are
motivated to approach pleasure and avoid pain is
well accepted, but that it was previously thought to
be a unitary system. By contrast, Higgins
6,7
proposed
that people have two basic self-regulation systems.
The prevention system regulates the avoidance of
pain or punishment, whereas the promotion system
regulates the achievement of pleasure or reward.
The prevention system involves goals that are expe-
rienced as necessities, obligations and things people
feel they have to do because failing to do them
might be painful. Such goals, for example, include
arriving on time at a meeting, following a procedure
for client referral, submitting an expenditure report,
etc. By contrast, the promotion system involves
goals that are experienced as wishes, desires and
things people feel they want to do because succeed-
ing in doing them might be pleasurable. Such goals,
for example, include exploring a novel idea for a
medical procedure, voluntarily performing medical
work for underprivileged patients, improving one’s
skill in a hobby, etc. The difference between the
prevention and promotion foci reflects the basic
conflict between the drive to preserve the status
quo and the drive to initiate change, or between
the need for security and the need for self-
actualisation.
6,8
To put it in everyday words, we
can distinguish between things we do because we
‘want to’ (promotion) and things we do because
we ‘have to’ (prevention).
ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174 1167
Feedback and feedforward
Regulatory focus and the reaction to feedback sign
How do the different regulatory systems react to
success versus failure, or the feedback sign?
Commonly, positive feedback, or success, produces
positive feelings, and negative feedback, or failure,
produces negative feelings. However, Higgins
6
demonstrated that success under the promotion
focus produces feelings that are not only positive but
are characterised by high arousal (e.g. feeling happy),
whereas success under the prevention focus produces
feelings that are positive but are characterised by low
arousal (e.g. feeling relaxed). Conversely, failure
under the promotion focus produces discouragement
(low arousal), whereas failure under the prevention
focus makes people feel tense (high arousal).
9
For
example, a successful outcome in medical research
(promotion focus) will lead to happiness, whereas a
successful outcome in a routine surgical procedure
(prevention focus) will lead to relief. However, a
failure in medical research will lead to disappoint-
ment, whereas a failure in a routine surgical proce-
dure will lead to stress.
High arousal emotions, whether in promotion or
prevention focus, are likely to reflect high motivation
in comparison with low arousal situations. This is
because arousal is a sign that a special effort or action
should be made. This aspect of Higgins’ theory led us
to hypothesise that the promotion focus, with its
concern with approaching pleasure and reward, will
be further mobilised by positive feedback that signals
that the object of desire is within reach and that more
rewards may be available with additional effort. In
parallel, we hypothesised that the prevention focus,
with its concern with avoiding pain and punishment,
will be further mobilised by negative feedback that
signals that the cause of pain or additional potential
punishment is present and needs to be dealt with. By
contrast, in the case of positive feedback in the
prevention condition, the signal indicates no emi-
nent punishment and hence effort to avoid punish-
ment can cease. Similarly, in the case of negative
feedback in the promotion condition, the signal
indicates poor likelihood of obtaining a reward and
hence no further effort to gain the reward need be
wasted and, again, effort can cease.
For example, if your administrator tells you that all
your accident reports (activating your prevention
focus) are messy (negative feedback) and create the
risk that you will be subject to legal action, you will be
likely to become hypervigilant and act to remedy the
situation. By contrast, if the same administrator tells
you that your reports are very well organised, you will
relax and are unlikely to do anything further with this
information. Yet, if, for example, your administrator
tells you that your initiative (activating your promo-
tion focus) was very well received by the hospital
director (positive feedback), you will very probably
become eager to meet the director, to consider
additional ways in which your initiative can be
demonstrated and perhaps more actively will seek to
generate new and improved ideas. By contrast, if the
administrator tells you that the very same initiative
was disapproved, you will be likely to be dismayed and
perhaps drop it altogether.
These straightforward examples are offered for the
sake of clarity, but the fundamental point is that we
expect to find an interaction between the regulatory
focus and the feedback sign in their effect on
motivation. Specifically, we predict that positive
feedback will increase motivation and performance
under the promotion focus, but debilitate motivation
and performance under the prevention focus. For
negative feedback, we predict the opposite: it will
increase motivation and performance under preven-
tion focus, but debilitate motivation and performance
under promotion focus.
Review of evidence for the regulatory focus–feedback
sign interaction
This prediction was repeatedly supported in our
various earlier studies,
4,5
in which promotion and
prevention foci were conceptualised both as chronic
and situational variables. Specifically, in our first set
of experiments,
5
we presented research participants
with a hypothetical scenario and requested them to
estimate whether they would increase or decrease
their effort after receiving feedback.
Situational regulatory focus was manipulated by
telling half of the respondents to imagine they were
working in a job they had to keep because they were
afraid of being left without income (prevention
focus). The second half were asked to imagine they
were working in a job they had always desired to have
and that they wished to develop and advance in that
job (promotion focus). Feedback sign was manipu-
lated by telling half of the respondents that their boss
had just told them they had failed in their task
performance and the other half that their boss had
told them they had excelled in their task performance.
Motivation (after the feedback) was assessed with
one item to be rated on an 11-point scale: ‘Relative to
your effort thus far, how much effort do you intend
to exert next?’ This intention to invest effort was
significantly higher after either positive feedback in
1168 ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174
A N Kluger & D Van Dijk
the promotion condition or negative feedback in
the prevention condition relative to negative
feedback in the promotion condition or positive
feedback in the prevention condition.
In the second experiment
5
we moved out of the
laboratory and presented working people with a
similar hypothetical scenario in which feedback sign
was experimentally manipulated but regulatory focus
was measured as a chronic individual difference. To
measure chronic regulatory focus, we used three
different operationalisations. The first was based on
values, which were measured with a shortened
version of Schwartz’s value instrument known as the
Schwartz Portrait Questionnaire.
10
We divided the
participants into three groups on the basis of two
median splits. The ‘Promotion’ group included
people who were both high on values of self-direction
and stimulation and low on values of security and
conformity. The ‘Prevention’ group included people
who were both high on values of security and
conformity and low on values of self-direction and
stimulation. The ‘Undetermined’ group consisted of
a smaller group of people who were either high or
low on both sets of values. The second operationali-
sation of chronic regulatory focus was based on
occupation. Occupations can be classified, according
to Holland’s model of vocational interest,
11
into six
categories, four of which are clearly tied to regulatory
focus both theoretically and empirically.
12,13
Specifi-
cally, promotion focus seems evident in occupations
classified by Holland as Artistic and Investigative (in
our sample these included music teachers, copywrit-
ers, organisational consultants, researchers, and
research and development workers). Prevention
focus seems evident in occupations classified by
Holland as Realistic and Conventional (in our sample
these included secretaries, book-keepers, accoun-
tants, technicians and manufacturing workers).
Finally, we operationalised chronic regulatory focus
with respondents’ motives for holding their current
jobs. Specifically, respondents were asked to specify
why they had chosen their current job in an open-
ended question. Their answers were classified into
two groups: Promotion motives included reasons
such as self-actualisation, interest, challenge and ‘I
love my job’, and prevention motives included
reasons such as security, economic reasons, physical
condition and ‘I don’t have a choice’. The feedback
manipulation and the motivation measure were
identical to those used in the previous experiment.
With each of these three operationalisations of
chronic regulatory focus, we found the expected
effect of feedback sign. Specifically, positive feedback
caused higher motivation than negative feedback
when participants: (i) held high self-direction values
and low security and conformity values; (ii) were in
Artistic or Investigative occupations, and (iii) held
their jobs out of desire. By contrast, negative feedback
caused higher motivation than positive feedback
when participants: (i) held high security and confor-
mity values and low self-direction values; (ii) were in
Realistic or Conventional jobs, and (iii) held their
jobs out of necessity. Interestingly, the group whose
values could not be clearly identified as chronically in
either promotion or prevention focus was not
affected, on average, by the feedback manipulation,
which further supports our operationalisation of
regulatory focus with values.
Tasks as determinants of regulatory foci and their
interaction with feedback sign
To increase our confidence in the above results and
to expand theoretically the construct of situational
regulatory focus, we designed another set of exper-
iments.
4
The first goal of these experiments was to
demonstrate that different tasks induce different
situational regulatory foci and hence positive feed-
back will be more effective for ‘promotion’ tasks and
negative feedback will be more effective for ‘preven-
tion’ tasks. Secondly, we wanted to demonstrate that
the effects obtained with measures of hypothetical
motivation could be generalised to measures of actual
performance.
To advance our theoretical expansion of self-regula-
tion theory, we argued that certain tasks activate
prevention focus, whereas others activate promotion
focus. Tasks requiring vigilance – such as identifying
objects on a radar screen, detecting errors in
company reports, cleaning – keep individuals focused
on finding what is wrong and what they should avoid
(suspicious objects, errors, dirt, respectively). There-
fore, as a result of their nature, these tasks produce
prevention focus. By contrast, tasks requiring eager-
ness – such as seeking out new ideas, initiating
organisational changes, developing innovative prod-
ucts – focus on finding what is right and what might
be gained (ideas, changes, innovations, respectively).
Therefore, these tasks produce promotion focus.
Thus, schematically, promotion-focused tasks require
eagerness, creativity and openness, whereas preven-
tion-focused tasks require vigilance, attention to
detail and adherence to rules.
To demonstrate this possibility, we ran a pre-test in
which we asked managers to generate a list of typical
tasks and then asked seven experts in regulatory focus
ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174 1169
Feedback and feedforward
theory to classify the tasks to either promotion or
prevention. Experts agreed on 21 out of 23 tasks and
found 11 promotion tasks (e.g. generating ideas,
creative problem solving, assimilating a new technol-
ogy, challenging decision making, initiating
changes), 10 prevention tasks (e.g. detecting errors,
maintaining safety, book-keeping, work scheduling,
quality control) and two undetermined (neutral)
tasks (involvement in organisational politics, training
employees).
The first set of experiments used the scenario
methodology and manipulated three sets of
promotion and prevention tasks and employed three
separate samples. The first sample of Bachelor of
Arts graduates were presented with scenarios that
described working on an error detection (prevention)
task or an idea generation (promotion) task. The
second sample of undergraduate students from
variable backgrounds were requested to imagine
working on either a safety project (prevention) or a
career development project (promotion). The third
sample of medical interns were asked to imagine
working on either a drug control panel aimed at detecting
errors in prescribing drugs for patients (prevention) or
medical research aimed at improving the quality of patients’
lives (promotion). Feedback sign was manipulated by
telling respondents that after 1 month they learned
that ‘thus far’ their project was either failing or
succeeding. Motivation (after the feedback) was
assessed with one item to be rated on an 11-point
scale: ‘Relative to your effort on this project thus far,
how much effort do you intend to exert next?’
To reap the benefit of using three independent
samples, we ran two meta-analyses
14
of the simple
effects of feedback sign: one for the promotion tasks,
and one for the prevention tasks. Both meta-analyses
supported our hypothesis. Specifically, for the pro-
motion focus tasks, positive feedback yielded higher
intention to invest effort than negative feedback;
however, for the prevention focus tasks, negative
feedback yielded higher intention to invest effort
than positive feedback. In both meta-analyses we
found no evidence for heterogeneity in effects,
suggesting that the results were statistically similar in
all three samples.
Finally, we submitted our hypothesis to a more
stringent laboratory test based on actual perfor-
mance. Specifically, we assigned students to work on
either a prevention or a promotion task. The
prevention task was to detect errors in a list of
relatively simple, and solved, arithmetical calculations
that required accuracy and attention to detail. An
example item (which contains an error) is:
(+ 0.6) )()0.8) )(+ 0.7) = 0.9. The promotion
task was to generate as many uses as possible for a
particular object (e.g. a building block). For example,
uses for a building block include a door stop, a stand
for a planter, a base for shelves, a crude weapon and
an athletic weight. This task required creativity and
open-mindedness. The two tasks were presented by a
computer program and the experiment was con-
ducted in a computer laboratory. After working on
the task for 10 minutes, participants were asked to
pause and fill out a questionnaire. Meanwhile, the
computer informed them that the program was now
processing their task performance. After completing
the questionnaire, the participants received bogus
(and randomly assigned) normative feedback. The
feedback appeared on the screen as one of these
short messages: ‘Up to now your performance on this
task has been above average’ and ‘Up to now your
performance on this task has been below average’.
Participants were then asked to engage in the task
again, and pre- and post-feedback performance were
measured by the number of errors detected by the
participants on the error detection task, and by the
number of uses suggested by the participants on the
generating uses task. All performance scores were
standardised to allow clear comparison across condi-
tions. Finally, motivation was measured in a manner
similar to that in all previous studies both before and
after feedback.
As hypothesised, in the uses generation task (pro-
motion focus), positive feedback was followed by an
increase in performance and negative feedback was
followed by a decrease in performance. By contrast, in
the arithmetical calculation task (prevention focus),
positive feedback was followed by a decrease in
performance and negative feedback was followed by
an increase in performance. A similar pattern of
results was found for the motivation measure.
FEEDBACK (SIGN): DISCUSSION
Our works appear to have solved the mystery of
feedback sign and to explain why neither positive nor
negative feedback affects performance in a constant
manner. Specifically, our works suggest that the
benefit of either positive or negative feedback
depends on regulatory focus. Yet, our findings,
especially regarding negative feedback, are likely to
be further qualified by at least two considerations.
Negative feedback, on the basis of our work, should
improve motivation and performance for prevention
tasks, under prevention situations and for people
1170 ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174
A N Kluger & D Van Dijk
characterised by chronic prevention focus. At the
same time, however, negative feedback may have
detrimental effects that offset benefit such as those
hypothesised and summarised in this article. Con-
sider, for example, taking a course in statistics, which
many people take because they have to (prevention
focus), not because they desire to study the subject.
Now, imagine that you fail the midterm examination.
Your reaction may be complex. You may, as we
predicted here, have a heightened concern with
statistics, which will push you to try harder. Alterna-
tively, ruminating thoughts (‘perhaps I just cannot
master statistics’) may undermine your belief in your
abilities. Belief in one’s ability is labelled in psychol-
ogy as self-efficacy, a construct that was found to
predict actual performance on all types of task.
15
Suppose further that, despite the rumination and the
threat to your self-efficacy, you increase your effort
and work hard, but then also fail the next examina-
tion. This time, you may plunge into learned
helplessness.
16
Thus, our theory and findings may be
limited to initial reactions to negative feedback or to
tasks for which failure is not likely to undermine
belief in ability.
This additional complicating factor (belief in one’s
ability under prevention and promotion foci) must
wait for further conceptual and empirical develop-
ment. Practically, it demonstrates the complexity
inherent in providing advice on how to use feedback.
For example, to determine which type of feedback is
appropriate, we need to know not only which regu-
latory focus is salient, but also which aspect of
motivation (the urge to act or the belief in ability) is
stronger in each situation in order to be able to
suggest whether or not to use negative feedback. Even
ignoring this complexity, issues remain to be resolved
before we can determine how best to apply our
findings in practice, as outlined next.
Implications for the health care system
One difficulty in implementing our findings in the
workplace is that it is not always easy to identify a
situation as relating solely to a promotion or preven-
tion focus. A good example of a prevention and
promotion mix is the health care system. Doctors, for
example, are required to be aware of potential
mistakes and errors and at the same time to think
innovatively, to handle complex situations and to
make relatively risky decisions. What will be the proper
feedback strategy to help them improve their practice?
Although medical staff are faced with a mix of
prevention and promotion foci, the community seems
to emphasise error avoidance, risk management and
the minimising of losses over creativity and other
promotion-focused goals (although we realise there is
a large literature on adaptive expertise and innovation
that would appear to fit with promotion-focused
ideals). To test this hunch, we ran a simple test of the
frequency of the terms ‘diagnostic error’ and ‘error
reduction’ in PubMed and identified over 90 000
references, which may be compared with the less than
60 000 references obtained when a similar search was
conducted using ‘creativity’ and ‘opportunity’.
Clearly, this is a very coarse way of assessing the relative
balance between prevention and promotion foci in
the health professional community and countless
contextual variables will influence an individual
practitioner’s focus in any particular situation. It is
intriguing, however, to think about the impact that
the common conversations taking place within the
health professions might have on the general ten-
dencies of practitioners to be prevention-focused (e.g.
by altering their clinical behaviour because of the
threat of malpractice liability)
17
or promotion-focused
(e.g. by altering their clinical behaviour because of an
inner drive to improve the client’s health), and the
impact this may have, in turn, on health care profes-
sionals’ receptivity to feedback of different types.
Given the increasing emphasis on professional regu-
lation and the need to provide workplace-based
assessments in an impactful and credible way, these
issues may be worth exploring further.
What does this mean for practice? It implies not
only that tweaking the amount of positive versus
negative feedback is a very delicate endeavour, but
that many other features of the feedback (e.g. trust in
the source of feedback) may determine its effective-
ness, a complexity that led Kluger and DeNisi to refer
to feedback as ‘a double-edged sword’.
18
One
potential way to overcome the complexities associ-
ated with feedback is to transfer some of its key
ingredients to a different practice that is not marred
by the same problems. As it seems that the key
ingredient of feedback is the creation of a discrep-
ancy between a preferred standard and the actual
state of affairs (for a theoretical review, see
1
; for a
qualitative study describing this tension in medicine,
see
19
), perhaps a non-feedback discrepancy-inducing
technique known as the ‘feedforward interview’
3,20,21
will prove to be beneficial.
THE FEEDFORWARD INTERVIEW
The feedforward interview (FFI) is a multi-purpose
interview protocol designed to overcome some of the
ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174 1171
Feedback and feedforward
limitations of feedback. The FFI is a theory-based
modification of the appreciative interview compo-
nent of appreciative inquiry theory and methods.
22
Before explaining the theory behind it, we describe
the five steps of the FFI protocol (for a detailed
protocol, see
3
).
The FFI protocol
Introduction
‘I am sure that during your work [or your struggle
with your disease or any other domain of inquiry] you
have had both negative experiences and positive
experiences. Today, I would like to focus only on your
positive experiences.’
Story
‘Could you please tell me a story that happened
during your work [life] during which you felt full of
life [happy, energised], even before the results of
your actions became known?’ Note that we emphasise
‘before the results of your actions became known’ to
direct interviewees to consider cases in which the
mere activity was good for them, regardless of
organisational rewards or societal approval.
Peak
‘What was the peak moment of this story? What did
you think at the peak moment? How did you feel at
that moment [including your physiological
reaction]?’
The conditions (learning; inquiry)
‘What were the conditions, in yourself, others and the
organisation [physical, temporal] that allowed this
story to happen?’
The feedforward question
‘Recall the conditions that allowed you to feel alive
[at work]. Consider these conditions as road signs or
beacons that show you how to flourish [at work]. To
what degree does your current behaviour [at work] or
your plans for the immediate future take you closer
to, or further away from, the conditions that allowed
you to be happy [at work]?’
Comparisons of FIs with FFIs
Both feedback and the FFI appear to induce a
tension between a standard (a goal) and some
information pertaining to one’s standing relative to
the standard,
1,19
yet feedback focuses on external
standards and performance information, whereas
the FFI focuses on internal standards and perfor-
mance information. Specifically, whereas typical
feedback involves both an external standard of
evaluation (e.g. what constitutes an A grade in a
course is set by the instructor) and external infor-
mation regarding the distance from the standard
(e.g. the actual grade received), the FFI seeks to
establish both an internal standard of excellence
based on past performance and to generate internal
information on the distance from the standard that
currently exists or is expected to exist in the
immediate future. That is, the FFI seeks to create a
reflection process that firstly serves the interviewee
and his or her needs.
23
To uncover an inner
standard that supports a sustainable strategy of
superior performance, the FFI emphasises the
gleaning of a detailed story from the interviewee
(use of episodic memory). Recalling a story that may
be rare in one’s work experience or in one’s health
history may reveal new data that are not stored in
semantic knowledge (i.e. data that were not trans-
lated into a codified abstract theory of the person
regarding his or her more chronic behaviour). This
may create a novel insight regarding possible supe-
rior performance (increasing one’s belief in the
ability to perform) and a discrepancy that is likely to
drive people to replicate and expand their best
performance (simultaneously activating promotion
focus and high self efficacy).
Evidence for FFI effectiveness
The evidence for FFI effectiveness is largely clinical,
but some initial quantitative evidence is also avail-
able. Feedforward interviews have been used before
typical performance appraisals in several corpora-
tions
3
and were shown to yield new insights for
interviewing managers and to reduce resistance to
performance appraisal and to 360-degree feedback
from consultants.
3
In addition, the FFI was imple-
mented as a key component in an organisation-wide,
strength-based performance appraisal.
20
This ap-
praisal was perceived by senior managers to both
improve workplace relationships and supply insights,
via aggregated ratings, into strategic challenges
facing top management teams. One laboratory
experiment showed the FFI to increase the percep-
tion of learning relative to that in a group engaged
in the simple telling of positive and negative stories,
and to increase positive activation (positive moods
with high arousal) relative both to a group that only
told stories and a control group that was not
1172 ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174
A N Kluger & D Van Dijk
involved in any dyadic interaction.
21
In another
laboratory experiment, students were asked to con-
sider the goals that were most important to them
and rank them by importance (most respondents
ranked achieving academic success first). Next, the
students were administered either an FFI or an FI
delivered by a fellow student, or were asked to
reflect on their top-ranked goal. In the FFI condi-
tion, students were interviewed about a case or a
situation in the past in which they had attained
either the same (top-ranking) or a similar goal and
had felt good during the process. In the FI condi-
tion, the interviewing student asked the interviewee
about his or her goal and plans to achieve it and
then provided both negative and positive feedback
regarding the interviewee’s plans for achieving the
goal. Results indicated that the FFI increased,
relative to the feedback and reflection conditions,
the intention to pursue both the most important
goal and the second most important goal, on which
they were not interviewed.
21
In addition, the FFI
interviewers felt higher self-efficacy and reported
more learning than the feedback interviewers. Thus,
it seems that, at the very least, the FFI can generate
feedback-like processes that may positively affect
performance (by enhancing the intention to pursue
goals) and at the same time benefit the interviewer.
Whereas the existing evidence is promising, addi-
tional theoretical and empirical work is needed to
substantiate claims regarding the FFI. However,
based on practical experience, we can consider the
possible application of the FFI in medical education.
A proposal for using the FFI in medical education
There is a multitude of possibilities for utilising the
FFI in medical education. Firstly, seasoned instruc-
tors could be interviewed by colleagues to generate
peak stories from their careers. The conditions that
emerge from those stories may point to critical
prerequisites for excellence in medical practice, at
both the individual (e.g. knowledge, curiosity) and
system (e.g. good relationships with the patients, no
time pressure) levels. Although some of the condi-
tions to be discovered are very far from the common
reality of the work of many doctors (e.g. absence of
time pressure), exposing these conditions may
highlight, for both students and the medical estab-
lishment, some of the ideal conditions that facilitate
the delivery of excellent medical care. Indeed, a few
FFIs we carried out with general practice doctors
indicated that among the key factors that make
doctors happy and proud (generating feelings of
being ‘full of life’ at work) were building relation-
ships with patients and having ample time. These
conditions are standards that, if they are accommo-
dated, may both support the doctor’s well-being and
facilitate the delivery of outstanding results, and
prevent burnout and dissatisfaction.
24
The doctor
and the establishment will then be faced with
feedforward questions pertaining to how and to what
extent their current practices, or their plans for the
future, differ from the situational and personal
factors that are believed to have yielded excellence in
the past.
Another possible application refers to teaching
medical educators to periodically interview their
interns with regard to peak experiences. This may
help interns to discover their own strengths and
identify their career aspirations, and may prepare
the ground for providing necessary feedback in a
manner that does not threaten the self of the intern
and in a way that builds, rather than destroys, his or
her relationship with the mentor.
CONCLUSIONS
In this article, we have shown that the effects of
feedback on motivation and performance are very
complex and at times result in effects opposite to
those intended. We offer a deeper understanding of
people’s reaction to feedback via the concepts of
promotion and prevention. We show that positive
feedback motivates more than negative feedback
under a promotion focus and that this effect reverses
under a prevention focus. To offset some of the
risks associated with feedback without losing its key
motivating principle, we offer feedforward and the
FFI as a means to enhance performance within the
health care system. Further exploration of the FFI is
required, but the conceptual issues outlined here are
likely to provide guidance regarding ways in which
the efforts of educators and regulators can be
maximally beneficial for both the individual clinician
and the profession.
Contributors: ANK wrote the initial draft of this paper. DVD
revised the draft and provided medicine-related examples
and references. Both authors approved the final manuscript
for publication.
Acknowledgements: none.
Funding: this paper was supported by a grant to ANK from
the Recanati Fund at the Jerusalem School of Business
Administration, Hebrew University of Jerusalem, Jerusalem,
Israel.
Conflicts of interest: none.
Ethical approval: not applicable.
ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174 1173
Feedback and feedforward
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Received 7 May 2010; editorial comments to authors 2 June 2010,
1 July 2010; accepted for publication 13 August 2010
1174 ªBlackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1166–1174
A N Kluger & D Van Dijk
