Literature
Expert Consult
Published December 14, 2022
Feedback is defined as information describing an individual’s performance in a given activity that is intended to guide their future performance. Medical trainees are becoming increasingly aware that feedback is a critical component of clinical training. In a two-part series on improving formal feedback exchanges, we will focus on the residents’ role in both receiving feedback as they become independent practitioners and giving high-quality feedback to junior trainees and supervisors.
In this first post, we review the basics of feedback exchanges, including a comparison of definitions for feedback and assessment, key characteristics of high-quality feedback exchanges, and barriers to feedback. In part two, we will address how to set expectations around feedback exchanges (including feedback exchanges within a hierarchy) and handle negative feedback, as well as provide other tips to help improve formal feedback exchanges.
Feedback vs. Assessment
A significant first step in understanding what constitutes high-quality feedback is to differentiate feedback and assessment. The two concepts both overlap and have marked differences.
Feedback involves an exchange regarding performance in an activity or skill and is intended to direct future behavior. Feedback is given in small aliquots, ideally in an iterative fashion over a short period of time.
Assessment is a summative evaluation intended to describe performance over a period of time and compared to a set of specific training-level expectations.
| Characteristics of Feedback vs. Assessment | ||
|---|---|---|
| Feature | Feedback | Assessment |
| Setting | Throughout the workday | After a period of multiple observations |
| Mode | Primarily verbal | Documented, frequently via centralized management platforms |
| Frequency | More often | Less often |
| Pattern of dissemination | Ongoing exchange between faculty and learner | Reported formally to the trainee, supervisors, and education leaders |
| Goal | Formative | Summative |
| Time period | Current performance | Retrospective summary of overall performance |
| Example | Attending gives specific, directly observed feedback regarding knee exam after resident examines a patient | Attending completes assessment form to describe overall performance of a resident over the past 3 months in a primary care clinic |
Key Elements of Feedback
We created the STAROS model to describe characteristics of high-quality feedback aimed at improving the utility of the feedback. As described in the table below, ideal feedback is specific, exchanged in a timely fashion, actionable, built around realistic expectations, based on directly observed behaviors, and skill(s)-based.
| STAROS Model: Characteristics of High-quality Feedback | |
|---|---|
| Specific | Provide detailed, skill-based information on what trainee did well or needs to improve on |
| Timely | Deliver in real time when possible, and deliver in small doses |
| Actionable | Include an action plan to guide future behavior |
| Realistic expectations | Create shared expectations that are trainee-level specific |
| Observable | Find opportunities for direct observation |
| Skill(s)-based | Describe activities and/or behaviors demonstrated in a given skill, not personality characteristics |
Specific: High-quality feedback includes specific details of the observed skills to allow the receiver to understand the elements of their performance that are being described.
Example of specific feedback: “Good job following a systematic format in the physical exam and explaining exam maneuvers to the patient.” This feedback identifies the precise, skill-based behaviors that made the exam successful and should be repeated in the future.
Example of nonspecific feedback: “You did a good job performing the physical exam.” This feedback is not specific and does not identify the precise skill-based behaviors demonstrated by the learner. The student lacks a road map of specific behaviors to repeat in the future.
Timely: The timeliness of feedback is an important feature for the following reasons:
Feedback should be delivered in real time, immediately or soon after the observation of behavior. The benefits of feedback exchanges attenuate with the passage of time due to recall bias for both the feedback giver and receiver. If a resident is given feedback about medical decision-making from 3 months ago, the original behavior may not be recalled accurately, and the resident loses some opportunity to change their behavior prospectively.
“Time” in feedback can also refer to the amount of time spent in the actual feedback exchange. Finding the time to deliver feedback amid a busy patient-care day is a frequent challenge for clinicians, especially if the feedback exchange needs to be lengthy and comprehensive. Feedback overload can be cognitively overwhelming and not useful to the receiver.
Actionable: All feedback should be actionable, allowing the receiver to modify behaviors based on the feedback, where appropriate. If feedback is too generic or describes a behavior that cannot be modified, it is not useful to the receiver. The feedback provider must not only give feedback, but also include a plan for the learner to develop their skills, knowledge, and attitudes related to that activity.
Realistic expectations: It is vital that all participants in a feedback exchange have a shared understanding of the expectations for that activity. A supervisor should have different expectations for a 3rd-year medical student completing an oral presentation than for a senior resident. The training-level–specific expectations for any activity should be discussed in advance so that the feedback exchange can be directed and calibrated to the learner’s level.
Observable: Feedback is most useful if it is based on direct observations, including specific descriptions of the performance of the trainee. In some cases, this “observation” can occur after the actual activity (e.g., if an interaction is recorded or if a written discharge summary is being reviewed). As trainees progress in their careers or on to the attending role, they will increasingly be responsible for giving feedback for activities they did not directly observe. For example, due to hierarchy issues and power balances, a nurse may describe an interaction they had with an intern on the team to a senior-level resident because they do not feel comfortable giving feedback directly to the intern. In this setting, the resident is responsible for giving feedback to the intern, at a minimum describing the perception that the nurse had of the intern.
Skill(s)-based: Feedback should focus on specific activities, behaviors, or both that can be developed, modified, and evaluated as part of training. One strategy to mitigate bias in feedback is to focus the feedback on the behavior or activity and avoid directing it toward the intern’s personality characteristics.
Feedback Domains
Feedback in medical education can occur in several domains, including physical exam skills, procedure skills, oral presentations, patient assessments, and management plans. Although most feedback focuses on the clinical domain, opportunities exist to provide and receive feedback in nonclinical professional training activities. The following table lists several potential domains for feedback:
| Possible Domains for Feedback | |
|---|---|
| Interactions with patients, health care team members, and consultants | Timeliness of completing notes |
| Physical exam skills | Documentation skills |
| Clinical reasoning | Efficiency |
| Medical knowledge | Professionalism |
| Email correspondence | Responsiveness to feedback |
| Scholarly work | Teaching |
| Completion of administrative duties | Surgical/procedural skills |
Barriers to Feedback
Trainees and faculty would agree that high-quality feedback exchanges are a critical element of physician training. So why is there a constant struggle to provide high-quality feedback in medical education? Several common barriers to feedback are listed in the table below.
| Common Barriers to Feedback Exchanges | |
|---|---|
| Giving negative or sensitive feedback can be challenging | Not enough time |
| Giving feedback to peers, friends, and colleagues may feel awkward | Conflicting priorities |
| Lack of physical space to give private feedback | Receiver may not recognize that they are getting feedback |
| Power differentials may constrain feedback from junior trainees to senior residents and faculty | Negative emotional responses |
| Lack of observations as a basis for feedback | Lack of growth mindset in the receiver |
Potential Solutions to Selected Feedback Barriers
Although no universal solutions exist to remove barriers, the following are some ways to help minimize barriers to feedback.
Time: Making time for feedback exchanges during busy clinical days can be difficult. Time can also come into play when the intern is experiencing feedback overload:
Create a scheduled time and day for feedback exchanges, such as “Feedback Fridays,” when feedback exchanges can replace planned teaching.
Give feedback in small aliquots to avoid the potential for feedback overload.
Physical space: Finding an appropriate place to give feedback, especially negative or sensitive feedback, can be difficult (e.g., being limited to hallways, busy clinical wards, and operating rooms is less effective).
Seek alternative options, such as scheduling feedback exchanges in a private office or taking a walk to get coffee.
Receivers may not recognize they are getting feedback: Learners can misinterpret feedback discussions as teaching points. Feedback must be labeled using phrases such as “I am going to give you feedback now” so that all parties understand the context of the conversation.
Method of Feedback Exchange
We recommend using a modification of the Ask-Tell-Ask Feedback Model with the addition of an “Add” section at the end.
| Modified Ask-Tell-Ask Tool | ||
|---|---|---|
| Description | Example | |
| Ask | Feedback giver asks the receiver to self-reflect and assess how they performed the activity. Ideally, feedback is an assimilation of self-assessment with external feedback. | “How well do you think you discussed the diagnosis and management plan with the patient?” |
| Tell | Feedback giver provides an assessment of the activity based on expected performance for a trainee at that level of training. | “I thought that you highlighted the key elements and set the correct expectations. I would suggest avoiding medical jargon and maintaining eye contact with the patient.” |
| Ask | Feedback giver asks the receiver to identify one or two steps for improvement in the activity. | Faculty: “What will you do to improve this skill?” Resident: “I will start reading more about the acute management of congestive heart failure.” |
| Add | Feedback giver provides one or two suggestions of resources for improvements. The “Add” step also involves follow-up planning for further observations and feedback exchanges. | “I suggest that you read [textbook name] to help guide your next exams. I will then observe you doing another exam in 2 days so that I can assess if your skills have improved and provide more feedback.” |
Conclusion
High-quality feedback is an important component of residency training and a tool to help trainees develop the skills, knowledge, and attitudes required for their career. All physicians, including trainees, have a responsibility to provide feedback to their colleagues, especially junior students and residents. Although barriers exist to providing and receiving high-quality feedback, there are techniques to help overcome these barriers, including using systematic approaches to feedback delivery.
