Expert Consult

By Craig Noronha, MD; Sonia Ananthakrishnan, MD

Published April 19, 2023


In the first part of this series, Improving Feedback Exchanges with Residents: Can You Hear Me Now?, we reviewed basic knowledge and skills related to feedback exchanges in medical training. We defined the difference between feedback and assessment, highlighted the key components of high-quality feedback, identified barriers to feedback exchanges, and introduced a feedback tool. Now, in the second part of the series, we take a deeper dive into the skills and attitudes necessary for effective feedback exchanges and best practices.

Setting Expectations

High-quality feedback exchanges require a shared understanding of expectations among all stakeholders. A shared mental model of appropriate expectations for each trainee creates the platform for effective feedback exchanges. The following factors support effective feedback exchanges:

  • Psychological safety: Creating a sense of psychological safety in the learning environment encourages interpersonal risk-taking, expression of vulnerability, and the contribution of perspectives, all without fear of negative consequences.

  • Formal discussion: Faculty and upper-level residents should begin a rotation with a formal discussion to set feedback expectations, create a culture where feedback exchanges become a routine part of the workday, and destigmatize risk-taking or being incorrect. These discussions can also be used to elicit learner goals and guide targeted observations and feedback. If possible, members of the feedback dyad should communicate in advance about the goals for an activity or period of time.

  • Learning contract: The following questions have been suggested as a template for a learning contract that spells out specific areas for growth identified by the learner and that solidifies benchmarks for success.

    • What do you need to learn?

    • What resources do you need to achieve your goals?

    • What will demonstrate that you have been successful?

Key Factors for Accepting Feedback

The receipt of feedback is heavily dependent on several factors, including the trainee’s willingness to accept feedback and their ability to perceive it as a tool for growth and development as well as a mechanism for supporting their mastery in a specific domain. The highest-quality feedback exchanges occur when all stakeholders are invested in the process. Learners can feel empowered by taking the following steps at the beginning of a rotation or prior to a specific activity to enhance the quality of feedback they receive.

  • Perform a self-assessment both prior to starting and during a rotation, an elective, or an assignment. Self-assessment involves reflecting on one’s personal skills, knowledge, and attitudes as they relate to upcoming clinical and nonclinical duties. The learner must be aware of the importance of self-assessment in the feedback encounter, be encouraged to proactively seek feedback exchanges based on self-assessment, and actively suggest specific times and dates for observation.

  • Embrace a growth mindset, defined as “an implicit belief held by an individual that intelligence and abilities are changeable.” At its core, a growth mindset means a learner perceives challenges and failures as opportunities for growth and development. To support the growth mindset in the educational environment, mistakes and challenges must be normalized.

  • Identify domains for assessment verbally or contractually (as described above) for themselves and observers. For example, prior to a cardiology rotation, if a trainee identifies that they want to improve management using goal-directed therapy for heart failure, they can arrange to be directly observed presenting heart failure assessment and plans, paired with specific feedback on this component of their presentation.

Key Factors for Successful Feedback Delivery

High-quality feedback includes timely, specific, and behavioral-based responses, ideally derived from direct observation. The following factors are associated with successful feedback delivery:

  • A standardized approach such as the Ask-Tell-Ask-Add Model (described in part one of this series) is one example of a framework that supports feedback encounters.

  • Keeping a “real-time” log of observations about trainees can facilitate both the feedback and assessment process and ensure that feedback discussions mirror final assessments.

  • Identifying specific activities to be used for observation and feedback, actively seeking opportunities for observation, and setting expectations for the feedback encounter.

Implicit Bias in the Feedback Encounter

Implicit bias in the feedback and assessment process stems from cognitive biases and stereotypes that all individuals bring to the workplace. Reliance on gut instinct or improvisation introduces bias into the process. This bias affects how we give feedback, the type of feedback we choose to exchange, and how it is received. Being aware of one’s own implicit biases can be achieved by using validated implicit bias tools (e.g., Project Implicit).

Creating a psychologically safe learning environment is key to sharing different perspectives and having a space where constructive feedback exchange is encouraged, without judgment. Learners and teachers can reconcile emotionally charged feedback by being intentional and understanding expectations. Trainees are encouraged to seek opinions and perspectives from a range of colleagues to ensure they are receiving holistic feedback. For example, 360-degree feedback or multisource feedback can help overcome the challenges presented by bias in feedback and assessment.

Advocacy–Inquiry Matrix Model

A method of feedback exchange introduced in part one is the Modified Ask-Tell-Ask Feedback Model. Another tool for feedback encounters is advocacy and inquiry, particularly useful in high-level skill learning and sensitive scenarios. The advocacy–inquiry matrix stems from the “debriefing with good judgment” model, which combines rigorous feedback with genuine inquiry. The focus is on creating an exchange that is nonconfrontational, supportive, and nonjudgmental, in an effort to share views and understand rationales.

Originally used in medical education to debrief after simulation activities, the matrix can be adapted for use in feedback exchanges. Key elements include the following:

  • Advocacy in feedback refers to stating one’s views.

  • Inquiry refers to asking questions to better understand a point of view.

  • The focus is on understanding the learner’s frame of mind and what learner-identified factors or actions led to a specific outcome, rather than “correcting” a behavior.

  • Learners “advocate” for their approach and actions by describing their thought process. Feedback givers “advocate” by giving their perception of outcomes or impact and “inquire” using open-ended questions to understand the learner’s perspective (e.g., probing to understand how a decision was made or asking about specific factors that may not be obvious).

  • The goal of inquiry is to generate action as opposed to detailing potential excuses. Together, both the learner and feedback giver can integrate the inquiry-generated data and advocacy viewpoints to highlight areas of success and areas for growth. A careful balance between advocacy and inquiry is needed in order to be productive. The following table offers an example of advocacy–inquiry matrix phrases that can easily be incorporated in feedback exchanges.

Advocacy-Inquiry Model for Feedback
I noticed that you...How did you think it went?
I saw that you...I wonder what your thoughts were?
I heard you say...Help me understand how you decided on that plan.
I perceived that you...How did you feel during that interaction?
I was concerned that...What would you do differently next time, and what would you not change?

Formative Feedback = Negative and Positive Feedback

Negative feedback is sometimes mistaken as the only form of formative or constructive feedback. However, positive feedback is also highly formative and constructive. Formative is defined as “serving to form something, especially having a profound and lasting influence on a person’s development.” Ideally, the amount of positive feedback (regarding high-performing activities) should equal the amount of negative feedback (regarding areas of improvement). Trainees need to receive feedback when they are doing something correctly, performing above expectations, or performing at a level that serves as a role model for other trainees — so that they know to repeat these behaviors. The exchange of positive feedback can also be important to engender trust between the feedback giver and receiver.

Handling Negative Feedback

The exchange of feedback focused on areas for improvement can sometimes be challenging to give, receive, and implement due to a receiver’s negative emotional response. Although making mistakes and exhibiting areas for growth are natural to the learning process, recognizing feedback as a self-improvement tool can be difficult in the milieu of graded assessments. (See the growth mindset above.)

With real-time feedback exchange, it can be jarring to receive negative feedback, causing trainees to default to fight-or-flight reflexes in their responses. When receiving feedback that causes a negative emotion, trainees can use the following strategies in an attempt to be intentional in their response and avoid the natural instinct to defend their actions.

  • Avoid excuses and a defensive or reactive response, but don’t let that translate to a lack of response.

  • Thank the giver for the feedback to keep the lines of feedback exchange open.

  • Ensure that details of the feedback are clarified, with specific examples provided when possible. Don’t agree or disagree with the feedback; initially, simply gather data to define the issues.

  • Once the specifics are collected, reflect on the feedback exchanged. Sometimes, reflection can be done in the moment, without a reactive negative response. However, in many cases, it is helpful to ask for time to reflect on the feedback and respond at a future date to allow time to process and understand that the feedback giver is simply sharing their perception.

  • Review difficult feedback with others (i.e., obtain a second opinion) to understand how to apply the feedback. Consider consulting with directors, other trusted supervisors, or peers to discuss concerns. Where appropriate, trainees may also be able to return to the original supervisor to ask for clarification.


Feedback is an essential component of medical training, combining timely and specific assessments of a trainee’s performance in an activity with actionable recommendations for improvement. To ensure that feedback is high-quality, it is vital that all stakeholders engage in the process with a constructive attitude and standardized skills. Feedback givers must understand the potential impact of implicit bias and actively work to reduce bias in feedback exchanges. Trainees benefit from an attitude focused on improvement and growth to make the most of their educational experiences, including feedback exchanges.

Craig Noronha, MD, is an Associate Program Director at Boston Medical Center/Boston University School of Medicine Internal Medical Program. He is on staff in the section of General Internal Medicine. He is the Director of Quality Improvement and Patient Safety Education and Director of Professional Development for the Residency Program. His educational research interests focus on residency scheduling models, professionalism, and feedback. He has published several articles related to scheduling models. He currently co-directs a Department of Medicine initiative to improve feedback exchange between all members of the department. Dr. Noronha has been an advanced user and physician lead for Boston Medical Center Information Technology, including acting as a physician consultant for numerous projects.
Sonia Ananthakrishnan, MD, is an endocrinologist in the Department of Medicine at Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center. She is the Director of Student Education in the Department of Medicine and the Medicine Clerkship Director. Her areas of interest are neuroendocrinology and medical education, with a focus on feedback. She completed her medicine residency at the Hospital of the University of Pennsylvania and her endocrinology fellowship at Boston Medical Center.