Teaching on the run tips 10: giving feedback

Giving trainees feedback means letting them know, in a timely and ongoing way, how they are performing. Providing feedback is an essential part of training junior doctors.1-4 Most trainees welcome the opportunity to discuss their strengths and areas for improvement. Feedback should encourage self-reflection, raise self-awareness and help students plan for future learning and practice. Medical students and junior medical officers report that feedback doesn’t occur frequently enough and that it is not always conveyed effectively.5 In contrast, teachers feel they give more feedback than learners claim to receive.6 Perhaps we can do better. The Confederation of Postgraduate Medical Education Councils recommended in 2001 that effective feedback should be given to students and junior doctors as a strategy for preventing distress.7

Feedback may be formal or informal. Formal feedback is planned as part of appraisal and assessment1,4 and occurs episodically (eg, at the middle and end of a rotation). It may cover specific areas or outcomes as set down by the hospital or a clinical college. Informal feedback should be given on a daily basis in relation to specific events (eg, managing a case or doing a procedure). Indeed, daily feedback should be part of the culture of our hospitals and other sites of training.

Ensuring good feedback requires:1-4

• Adequate time;

• Clear goals and outcomes — so you know what you are appraising or assessing;

• Direct observation of learners — so you know how well they are doing; and

• Skills in giving positive and negative feedback — so you are an effective facilitator of junior doctors’ development.

Positive critique, in which the trainee is asked to speak first, is a powerful framework for giving feedback (Box). This approach, while not avoiding negative feedback, emphasises the positive and encourages self-reflection. Often the positive critique approach is easier on the supervisor, as the trainee may bring up areas of concern first, so you can agree rather than break the bad news! A mismatch in trainer/trainee understanding revealed by feedback raises flags as to trainees’ insights.

As outlined in “Tips 8”,4 when giving feedback, make sure you cover all important areas of professional competence (knowledge, skills, communication, attitudes) and collect good data (from multiple people on multiple occasions) on which to base your feedback. Feedback should not skim across the surface task. Good feedback should:

• Be timely. Give feedback soon after an event and as regularly as possible (preferably daily or weekly). Waiting till the end of a rotation is too late. Don’t give feedback at times when you or the trainee are tired or emotionally charged.

• Be specific. Trainees want the specifics, rather than a global “overall, you are doing fine”.

• Be constructive. Help provide solutions for areas of weakness. The positive critique, which looks at “what can be improved” rather than “what is wrong”, encourages looking for solutions.

• Be in an appropriate setting. Positive feedback is effective when highlighted in the presence of peers or patients. Constructive criticism should be given in private — an office or some neutral territory where you are undisturbed is ideal. Phones should be off the hook, mobiles and pagers turned off.

• Allow the trainee input. Trainees should be given the chance to comment on the fairness of the feedback and to provide explanations.

• Involve attentive listening.

• Focus on the positive.

• Avoid jokes, hyperbole or personal remarks (concentrate on the act or behaviour, not the person).

• Try not to dampen positive feedback by qualifying it with a negative statement (“I was very happy with your presentation, Sharon, BUT . . .”; “Overall, James, we are pleased with your performance, HOWEVER . . .”).

Using regular feedback to encourage, enthuse and correct learning9 improves outcomes and helps to define goals. A survey of junior doctors on interactions with their supervisors showed that when feedback (especially when given in a positive fashion) was an integral part of the solution it was more likely to be associated with a positive view of medicine as a career and junior doctors having confidence in themselves as doctors.10 And remember, it is not just poorly performing doctors who want feedback — good doctors want to know how to be even better.