Guidelines for Providing Effective Feedback
Feedback can be readily adapted as an effective teaching tool into the unique educational environment of the ED. The seminal paper by Ende [1] delineates many of the principles of providing effective feedback in the clinical setting. These techniques, along with others, are reviewed in this chapter. Emphasis is placed on approaches that work well in the ED setting (Table 7.1). The preceptor should have a heightened awareness of the effect of providing feedback in front of a patient. As we provide feedback, we are guiding our learners along an educational continuum from the novice learner to a more seasoned senior resident or junior attending. Regardless of the level of the learners, it is important to provide feedback in a way that respects their autonomy without undermining the patient’s confidence in their ability to provide care. An example from my own residency training involves the repair of a laceration on a young child’s forehead. The attending physician entered the examination room as I was about to begin the procedure. He recommended that I approach the laceration in a particular fashion. I viewed his recommendations as guidance and feedback on how I should approach the laceration. However, the patient’s father viewed this as a reflection of my inexperience and proceeded to question if I was confident in my ability to perform the procedure. Bedside feedback should be delivered in front of the patient or family in a manner that does not detract from the autonomy of the trainee. In some situations, it is better to discuss certain aspects of the procedure away from patient or family or to guide the trainee at the bedside using nonverbal cues.
Table 7.1 Ten guidelines for effective feedback in the ED.
| Provide feedback that is positive |
| Refer to observations of specific behaviors or actions |
| Provide constructive feedback |
| Elicit self-assessment from the learner |
| Be well timed |
| Do not overwhelm the learner |
| Provide feedback that is nonjudgmental and nonevaluative |
| Make feedback a joint venture |
| Incorporate feedback into your teaching |
| Assist the learner in developing strategies for improvement |
The points to be kept in mind when providing feedback are discussed in the following sections.
Provide Feedback That is Positive
Instructors should provide positive feedback with the goal of praising the learner for a job well done, avoiding general statements such as “Good job!” or “You worked hard today!” There is always a time and place for such comments, for example, after a tough case or at the end of a busy shift. However, comments such as these offer little in the way of substance and are likely to be quickly discarded by the learner. Feedback is more helpful and should certainly have a longer-lasting effect when it includes descriptive comments such as, “You did a really good job today. When we were talking about Mr. Jones, you presented his case in a clear and concise fashion and came up with a focused assessment and management plan. I also liked the way that you explained the diagnosis to him and answered his questions.” The descriptive information emphasizes exactly what the learner did well, reinforcing attitudes and behaviors that are favorable. Positive reinforcement is always beneficial; however, if it is linked to specific behaviors, the feedback may have longer-lasting effects.
Refer to Observations of Specific Behaviors or Actions
A key to providing meaningful, long-lasting feedback is focusing on specific behaviors or actions of the learners, not on issues that are unlikely to be modified, such as personality traits. The focus should generally be on what learners do or do not do, as opposed to the learners themselves. Provide feedback about what they did or did not do, not about who they are. At times, it may be necessary to provide feedback to the learner about interpersonal relationships with patients, family, ancillary staff, and others, as this is an important aspect of patient care. If a learner has an abrasive or confrontational personality, focusing on what they do, that is, “I think you could have handled that difficult interaction with the consultant differently, here is how I would have approached it …, ” as opposed to focusing on who they are, “You were a real jerk with that consultant,” is the better way to provide effective feedback.
Provide feedback that is based on direct observation of clinical performance. Direct observation gives the teacher an opportunity to assess specific core competencies such as interpersonal and communication skills. Being descriptive and specific is an important aspect of providing feedback. For example, if a student generated a limited differential diagnosis for a patient with right lower quadrant abdominal pain, which of the following approaches to feedback do you consider more beneficial? “Your differential diagnosis for this patient was a bit limited” or “In addition to the causes of right lower quadrant pain that you mentioned, because she is pregnant, I would also consider ectopic pregnancy as part of your differential. This is important to always consider in a patient who is pregnant and presenting with lower abdominal pain.”
A key point is that, if possible, feedback should be anchored to behavior. Because of the time constraints faced by emergency physicians, time for direct observation of learners is limited in a busy ED. As a result, we are at times left with providing feedback on case presentation skills and using these skills as a surrogate for the history taking and physical examination. It is logistically easier, often because of time constraints, to provide feedback on the product of the patient interview as opposed to the process of the interview itself, although the two are equally important. Although providing feedback on aspects of performance such as case presentations is necessary, attention to observations of history taking and physical examination skills can add to the feedback process. This can be accomplished in the ED by observing brief aspects of the history taking and physical examination.
Provide Constructive Feedback
Properly delivered feedback can provide direction as to how a learner can improve his or her clinical performance [5]. Constructive feedback as opposed to constructive criticism can prevent certain actions or behaviors from being incorporated into the learner’s daily routine. The connotation of “criticism” versus “feedback” is particularly crucial when providing feedback that might be perceived as negative. As a result of the inherent difficulty in initiating a conversation about the “negative” aspects of performance, some teachers avoid being direct and forthright with the learner. When “negative” or constructive feedback is necessary for a trainee, an approach that is often recommended is to initiate the session with positive comments, followed by constructive feedback, and conclude with additional positive comments, that is, the “feedback sandwich.” Presenting feedback through this approach is more palatable for the instructor to deliver and for the learner to receive. Providing or receiving negative feedback creates anxiety for both the teacher and the learner. However, the goal of providing constructive feedback is to correct observed deficiencies to shape future behavior. This is best accomplished if the teacher reports on actions or behaviors that have been directly observed using language that is both descriptive and specific.
Elicit Self-Assessment From the Learner
An approach to consider when conducting a feedback session, either brief or formal, is to elicit learner self-assessment [6]. This technique can be an excellent icebreaker and can serve as an excellent adjunct or alternative to the classic feedback sandwich. Eliciting self-assessment from the learner can facilitate the feedback process by allowing the learner to express a view of their own performance. This self-assessment usually raises many of the same issues that the teacher wanted to discuss and allows the learner to feel more invested in the process. This approach might bring up other concerns that are equally important to the learner, which might not have been identified by the teacher. Self-assessment sessions can be initiated by the teacher posing open-ended questions: “How do you think you performed today?” “Is there anything that you could have done better today?” “Is there anything you feel you need to work on?”
Self-assessment is fundamental to the concept of self-directed learning and the maintenance of professional competence [7]. A key aspect of learner self-assessment is the assumption that a learner can accurately assess his or her own clinical performance. As teachers, we must keep in mind that the ability to accurately assess one’s own clinical performance is not a given. In fact, some learners with the greatest deficiencies (those who are the least competent) have poor insight into their own clinical performance [8]. Because of this, self-assessment should not be considered in isolation but should be coupled with feedback based on direct observation, as described earlier. Far beyond the typical challenge of providing effective feedback, the learner who lacks self-awareness regarding his or her own clinical competence presents one of the greatest teacher–learner challenges.
Be Well Timed
The timing of feedback is critical. To be most effective, it should be given immediately after observing an action or a behavior, as the window of opportunity to comment optimally is relatively narrow. It makes intuitive sense that feedback should be provided when the event is still fresh in the mind of the learner and the teacher. Feedback will have a much less desirable effect, if any, when delivered days or weeks later, after the details of an event are no longer fresh. This is applicable to any number of clinical scenarios, for example, patient interviewing, physical examination skills, case presentations, procedural skills. Suppose you observe a learner examining a patient with suspected pyelonephritis. Afterward, you might tell him or her, “I noticed that when you examined Mr. Johnson, you did not check for costovertebral angle tenderness. It’s always a good idea to check for costovertebral angle tenderness when evaluating a patient with suspected pyelonephritis.” Since the examination just happened, it would be easier for the learner to recall this and resolve to alter this behavior in case of similar patient encounters in the future. Constructive feedback such as this may have lasting effects on the learner if provided shortly after the patient encounter, especially if the feedback is presented in a constructive manner. That being said, there are times in the ED, in the midst of a cardiac arrest or the management of a critically ill patient, when feedback may need to be put on hold, unless it is necessary to provide immediate corrective action. In situations such as these, it is appropriate to set aside a few minutes after the patient has been stabilized or at the end of the shift to provide feedback.
Do not Overwhelm The Learner
In the ED, feedback is typically delivered in brief, informal sessions focusing on issues that the learner has the power to change, modify, or improve within the confines of a rotation, such as a discrete clinical skill or knowledge deficit. Brief feedback can be given at the bedside while observing a clinical or procedural skill or away from the bedside at the conclusion of a patient encounter or clinical shift. A key to effective feedback is to provide information in easily digestible portions rather than to inundate the learner with multifaceted information. The approach of brief feedback sessions applies to the ED setting, where many teachable moments are unplanned and unscripted and with time usually in short supply.
Feedback should be Nonjudgmental and Nonevaluative
For educators, interpersonal and communication skills are as important when providing feedback to a learner as they are when talking to patients and professional colleagues. The language and tone with which the instructor delivers feedback should be nonjudgmental and should convey respect for the learner as an individual. The instructor should not attempt to evaluate the learner’s clinical performance or overall level of skill or ability but should confine his or her comments to the situation at hand and the observable actions or behaviors. Evaluation by its nature is judgmental, with goals much different from those of feedback.
Consider a case in which a junior trainee falls into the trap of premature closure. The patient is a 34-year-old woman who presents with pleuritic chest pain. She smokes one pack of cigarettes per day and takes oral contraceptives. The trainee latches onto the diagnosis of chest wall pain and does not entertain the possibility that the patient could have a pulmonary embolism (PE). The skilled teacher would approach feedback in this case in a way that is constructive, nonjudgmental, and conducive to learning while avoiding humiliation and discouragement. Using such an approach, you might state to the learner, “I can see your point. Ms. Smith does have some chest wall tenderness on palpation. Her complaints may very well be that of simple chest wall pain; however, I believe we should consider PE as a possible explanation for her complaint, as this would be a very important diagnosis not to miss.” This allows the preceptor to acknowledge the trainee’s assessment of the case yet redirect with a suggestive style that is not offensive, placing emphasis on the clinically important points of the case rather than on the learner’s deficiency.
Make Feedback a Joint Venture
Feedback should be a joint venture, in effect, a two-way street. The principle shareholder, the learner, should feel empowered to solicit feedback from the preceptor. However, as we know anecdotally, this is not always the case. A feedback discrepancy has been noted in a study by Gil et al. [9], in which the authors identified substantial differences between the amount of feedback the faculty thought they provided and the amount the medical students thought they received. Instructors need to be explicit whenever there is concern that the learner is not receptive or may not be even aware of receiving feedback. At times, advice and mentoring are not considered feedback unless they are so labeled. Sometimes it is necessary to begin a discussion with a student or trainee by stating, “I’d like to provide you with some feedback on your performance.” At times, the overly aggressive learner may seek feedback after every case, a situation that may not necessarily be optimal. In such cases, boundaries may need to be set and the instructor may need to state that feedback will be provided at the end of the shift.
Incorporate Feedback into Your Teaching
Feedback should not be provided in isolation. It can be incorporated into various teaching models or methods of teaching. One such model, the One-Minute Clinical Preceptor, consists of five microskills that have been shown to constitute an effective approach to teaching: (i) obtain a commitment from the learner, (ii) probe the learner for his or her underlying reasoning, (iii) teach general rules, (iv) provide positive feedback, and (v) correct errors [10]. Feedback should be viewed as one facet of a much broader continuum of medical education.
Imagine a clinical scenario in which you are supervising a trainee who is performing arthrocentesis of the knee. As the learner proceeds through each step of the procedure—obtaining patient consent, equipment preparation, skin preparation, infiltration of local anesthesia—you might ask about the reasoning behind individual actions, offer guidance or suggestions about the specific procedural skill, comment positively on things done well, and correct any errors. By simply interacting with the learner in this informal, natural way, you have used an effective model for delivering feedback. A study involving medical students has shown that trainees receive more instructional feedback if selected procedural skills are observed directly [11]. To be most effective, feedback should be linked explicitly to direct observation of certain actions or behaviors.
Assist the Learner in Developing Strategies for Improvement
Constructive feedback is best followed by an action plan to assist the learner in improving performance. This may be one of the most important aspects of the feedback process. In our role as teachers, we are charged with guiding our learners through the educational process. Thus, it is necessary to provide learners with direction on how they may improve their clinical performance. At times, this aspect of feedback may take a bit of forethought on the part of the instructor. We should be ready to offer resources, ideas, or time to help a learner address any noted deficiencies or areas requiring improvement. This may be as simple as having the learner repeat the procedural skill while incorporating the instructor’s suggestions, assigning a book chapter or review article to read, or spending time reviewing cases, electrocardiograms, or radiographs. Incorporating feedback into simulation exercises also provides another opportunity to improve clinical performance in a controlled and safe environment. Real-time suggestions for improving clinical performance can be provided during brief direct observation sessions. Some learners are capable of creating an individualized educational plan, but most, if not all, benefit from the teacher who is available to monitor progress and assist in articulating and implementing the plan. A lack of consistent preceptor continuity can present a challenge to following up and monitoring the learner’s progress.
Additional Feedback Methods and Tools
Feedback Cards
Several authors have reported on simplified methods for providing effective feedback to learners [12–14]. These reports all revolve around using some type of feedback card to be completed by the preceptor to ensure that feedback occurs and to enhance its quantity and quality. A modified feedback note card was developed at the Medical College of Wisconsin [12]. A feedback note system such as this can easily be incorporated into the daily shift evaluation process that is used by many EM clerkships. However, faculty and resident educational development sessions and buy-in are critical to ensuring the consistency and success of such a program. Buy-in will be necessary from both instructors and learners when implementing any new program.
Written Feedback and Evaluation
In the ED, constraints stemming from time and patient care may prevent us from being able to consistently reflect on a trainee’s performance. Because of this, it is sometimes necessary to follow up on an interaction with a learner with written comments. This may be accomplished by completing an end-of-rotation written evaluation form or in a follow-up email that enables the teacher to provide an extended reflection on the trainee’s performance, supplementing the bedside feedback already provided.
Faculty members are frequently called upon to complete daily shift evaluations or end-of-rotation evaluations of learners. A clerkship or rotation grade may be based on a composite of these evaluations. Too often, preceptors do not make full use of this opportunity to deliver feedback. A well-designed end-of-rotation evaluation form should provide the instructor with the opportunity to give constructive feedback to the learner without fear that the comments will affect the rotation grade. Written communication gives us the advantage of being more calculating in our assessment and limiting any potential disconnect between the perceived intent and the likely perception of these comments. Written comments should support previous feedback and not surprise the learner with unfavorable comments that were withheld throughout the rotation to avoid giving negative feedback. If negative comments are provided without previous discussion with the learner, they may have an adverse effect and not serve the purpose of helping shape future positive behavior.
Many of the same guidelines proposed for verbal feedback should be adhered to when providing written feedback. A clerkship evaluation form is an appropriate avenue to praise a job well done and to provide constructive comments so that learners can modify behavior or actions as needed. Comments should be as specific as possible and, to close the loop, should include recommendations for performance improvement.
Formal Feedback Sessions
A more formal approach to providing feedback can be used in the ED at the conclusion of a clinical shift [15]. Formal feedback should be brief and delivered away from the bedside, in a quiet and controlled area, free of the distractions frequently encountered in the ED. For this type of feedback session to have the greatest impact on the learner, it should be uninterrupted whenever possible. In general, these sessions are more interactive than brief feedback sessions. A formal feedback session should provide an opportunity for the learner to ask questions. The session should be goal oriented, with specific topics on the instructor’s agenda. These types of sessions can occur before the start of a clinical rotation and may be an ideal time to review the learning objectives (competencies) of the rotation and the individual learner’s goals for his or her own performance. This type of meeting can set the tone for future feedback sessions.
Trainees who require more extensive feedback in response to documented unprofessional behavior or a trend of less-than-expected clinical performance may benefit from major feedback sessions, which can last 15–30 min or more. Major feedback sessions can be scheduled at the midpoint or end of a clinical rotation and are best held outside the patient care setting, in the instructor’s office. Semiannual feedback sessions commonly provided to EM trainees throughout their residency can be used to reinforce a job well done or address major deficiencies or concerns.
Feedback and the Accreditation Process
The process of providing formal feedback to trainees has been recognized as an integral part of the undergraduate and graduate medical education accreditation processes. The U.S. Department of Education recognizes the Liaison Committee on Medical Education (LCME) for the accreditation of medical education programs leading to medical degrees in USA. For Canadian medical education programs, the LCME works in collaboration with the Committee on Accreditation of Canadian Medical Schools (CACMS). The LCME outlines this expectation in the most recent version (May 2011 update) of the standards for accreditation of medical education programs [16]. The standards mandate that the directors of all courses and clerkships design and implement a system of formative and summative evaluation of student achievement. It is further expected that courses and clerkships provide students with formal feedback during the experience so that they may understand and remediate their deficiencies. In addition, EM residency training programs in USA should provide each resident with formative evaluations of their clinical performance. This expectation is described in the common program requirements (effective July 2007) set forth by the Accreditation Council for Graduate Medical Education (ACGME), the governing body responsible for accrediting the US graduate medical education training programs [17].
Faculty/Trainee Development
Like any other skill, the technique for providing effective feedback requires training and practice. However well intentioned individual instructors are, feedback is unlikely to occur on a meaningful level in the ED without a substantial amount of dedication to the education process by the faculty. There is no shortage of materials for training instructors or materials specifically designed for teaching and feedback delivery in the fast-paced environment of the ED [18–20]. Training can be obtained from faculty development programs that include feedback coaching as part of the curriculum (e.g., the Stanford Faculty Development Program) and through departmental or medical-school-supported faculty development courses. Trainees may benefit from a “Resident-As-Teacher” curriculum for EM, which includes a module on giving effective feedback [19].
Conclusion
Feedback is a crucial part of the medical education process and can advance the professional growth of medical students and trainees. Even in the busy and at times chaotic ED environment, instructors can deliver effective feedback using the strategies outlined and can incorporate the provision of feedback into other teachable moments. Individual instructors can choose among a variety of methods of feedback delivery to enhance the learning process and guide the future performance of students and trainees.
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