Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.
Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?
Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.
Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.
Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.
A New Approach
Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7
Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.