Feedback has a special role in medical education – For clinical learners, it is a key step in the acquisition of clinical skills, it leads to enhanced learning and is crucial in their development into competent clinicians. It is critical, in the context of patient care, as if feedback is not provided, mistakes go un-corrected, good performance is not reinforced and clinical competence may not be achieved at all.
Why do students and trainees continually complain about lack of feedback or poor feedback?
…..and why then is it done so poorly?
A number of situations contribute to the ‘lack of’ or ‘poor’ feedback
- misconception between the terms feedback and evaluation/assessment.
- a focus on the trainees themselves rather than on the trainees observable behaviours
- lack of observation – clinical skills frequently unobserved, and
- when they are observed… the information doesnt actually get back to the student/trainee or is handled inappropriately ie poorly communicated
The aim of this post is to provide clinical teachers with
- a clear understanding of the feedback process
- analyse some of the barriers that interfere with feedback
- highlight the consequences for clinical training if feedback is ignored or handled poorly
- provide practical guidelines/ examples of giving effective feedback
The difference between feedback and assessment
When we give feedback, we are observing performance (of an activity/skill) in order to provide information that will guide future performance of that activity or skill..feedback is formative and specific and promotes future learning. It is not a judgement on performance. Assessment on the other hand is summative, it comes after the fact and presents a judgement on how well or poorly criteria is achieved, often in relation to a specific standard.
The feedback process
Articulate learning goals
We firstly need to understand the learning goals of the student or trainee, the conversation needs to occur up-front and explain why it is important, and what we hope to both get out of it. i.e. Learners identify what they would like to get out of their rotation (or learning activity) These can be articulated as specific, measurable….. Once the goals are set, it is then important to close the loop and provide feedback on how the learner achieved those goals.
To ensure the correct information is given, the supervisor needs to ‘observe’ the learner… actually see first hand ‘how’ they perform a clinical task, skill or manage a patient encounter. Therefore feedback should be based on first-hand data – if you weren’t there you didnt see the patient, don’t judge what was going on.
2. The feedback meeting
Two way conversation or exchange (being open)
Feedback involves a mutual two way discussion where both supervisor and learner contribute their perspectives of the activity/performance. Invite dialogue and reflection. The learner reflecting and the supervisor questioning/guiding/telling. Feedback is effective when the learner is offered insight into what he or she actually did as well as the consequences of those actions. If is a valuable component to improve learning as it highlights the dissonance between the intended result and the actual result…which provides the impetus for ‘change’
Questioning and telling
The key strategies utilised in this discussion are good questioning techniques and then being able to ‘tell’ the learner, providing specific examples on what they did well, plus clear and specific ways on how they can improve.
The questioning techniques also help students reflect and assess their performance and at the same time, gain more insight into what they did well and what areas need improvement.
It is of no use to a learner, if the feedback is vague -“you are doing a great job” doesnt provide useful feedback at all. Also avoid subjective statements “that was stupid, wasnt it? helps no-one. Having observed the performance, the supervisor is able to provide explicit details on the learners strengths and what areas need improvement, with suggestions on how they can improve.
Supervisors need to be honest with the learner about their performance and how they see things. Providing the learner with constructive ways, and specific examples of what they can do in the workplace or next time they manage a patient that will actually ‘improve’ their approach. However dont overload the learner – stick to the behaviours they can change – and plan in advance on one aspect they can focus on to develop. Working through cases can help the trainee pull out learning points to other context or patient situations.
Questioning: what do you think went well?
Telling: You interacted with that patient well
Questioning: What areas would you like to improve
Telling: You should try this next time
Questioning: Where do you see yourself now in relation to your learning goal
Telling: You are developing excellent communication skills
Say Thank You