Research article
Open Access

Gender and Feedback in Medical Education

Yemisi Jones[1], Pamela Murray[2], Robin Strader[3], Joseph Nyachae[3], Rashida Khakoo[3]

Institution: 1. University of Cincinnati College of Medicine/Cincinnati Children's Hospital Medical Center, 2. West Virginia University , 3. West Virginia University
Corresponding Author: Dr Yemisi Jones (Yemisi.jones@cchmc.org)
Categories: Medical Education (General), Students/Trainees, Teachers/Trainers (including Faculty Development)
Published Date: 12/02/2018

Abstract

Background: More women are entering medical school and faculty positions, creating increased opportunities for interactions across gender during medical education. Little is known about how gender affects attitudes towards and preferences around feedback.

Objective: To explore differences in giving and receiving feedback between men and women in clinical education.

Methods: An anonymous survey was distributed to 3rd and 4th year medical students, residents, and clinical faculty at West Virginia University School of Medicine at the start of the 2014-2015 academic year. Participants were surveyed about their attitudes, expectations, and knowledge about feedback in the clinical educational setting. Responses were mostly on a 5-point Likert scale. The authors used Fisher’s exact test (FET) and binary logistic regression to identify differences in responses by gender.

Results: Of 762 potential respondents, 155 (20%) completed the survey. More women preferred to receive constructive feedback in written form (FET p = .05, OR = 4.18, p = .009).  They also preferred to give feedback in written form (FET p = .04, OR 4.98, p = 0.003). However, a greater proportion of men preferred to give constructive feedback face-to-face (FET p = 0.003, OR NS), reported liking to give constructive feedback (OR = 4.40, p = 0.04), and felt comfortable giving constructive feedback (FET p = .03, OR = 10.21, p = 0.003). 

Conclusions: These findings suggest there are differences in the preferences and comfort men and women have for giving and receiving feedback. This has implications for approaches to clinical preceptor training around feedback.

Keywords: gender differences; feedback; medical education; sex differences

Introduction

The importance of feedback for improving performance in clinical education is well established (Chowdhury & Kalu, 2004; Ende, 1983; Hewson & Little, 1998; Schartel, 2012).  Moreover, there is evidence from other fields that men and women differ in the type of feedback they give, their preferences in how they like to receive feedback, and their response to feedback (Brewer, Socha, & Potter, 1996; Evans & Waring, 2011). For instance, male supervisors have been noted to give more specific corrective feedback than female supervisors (Brewer et al., 1996).  Male student teachers have been shown to be more receptive of group feedback than female student teachers (Evans & Waring, 2011). There are now more opportunities for cross-gender interactions in medical education, with the proportion of women entering medical schools in the United States at nearly fifty percent (Diana M. Lautenberger, Dandar, Raezer, & Sloane, 2014). The proportion of women in faculty positions is also increasing although lower, near one-third (Diana M. Lautenberger et al., 2014). The medical education literature is sparse regarding gender differences in feedback, so it is unknown if the differences seen in the business and education literature are applicable in clinical settings. We sought to explore potential differences in attitudes and expectations between men and women in giving and receiving feedback in clinical education.

Methods

Setting and Participants

West Virginia University (WVU) School of Medicine 3rd and 4th year medical students (n=196), residents (n = 412), and clinical education faculty (n = 154) were notified of the opportunity to participate in the study via direct email with a secure link with one reminder from June to August 2014. Student electronic newsletters and posted flyers were also used to encourage participation.  The total number of respondents was 155 (response rate of 20%), with a sample similar demographically to our population (Table 1). The survey was administered anonymously via Qualtrics (a web-based software). A $25 gift card was offered to the first fifty respondents.

Survey Design

We designed the survey to explore gender differences in attitudes, expectations, and knowledge about feedback.  The survey included subject demographic information as well as fifteen statements on preferences when receiving feedback and twenty-four on giving feedback.  The majority of questions required responses on a five point Likert-type scale, from “strongly agree” to “strongly disagree” or “never” to “always.”  We also included questions with the opportunity for free text responses. Some questions were based on the feedback portion of the Stanford Faculty Development Program Questionnaire (SFDPQ26), a validated instrument that assesses 7 areas of clinical teaching effectiveness, including feedback 8. The survey was reviewed by one expert in feedback and another in survey methodology for both content and design.  We piloted the survey with 5 participants, who provided feedback on readability, functionality, and clarity of the questions.

This study was reviewed by the WVU Institutional Review Board and approved for exempt status. 

Analysis

We summarized and compared survey responses by gender and level of training using the Fisher exact test as well as binary logistic regression to adjust the responses for gender, age, training, and department. All statistical tests were two-sided tests, with a = 0.05. We used the R software environment reference index version 3.2.0 for statistical computing and graphics for all statistical analyses (R Foundation for Statistical Computing, Vienna, Austria).

Results

Receiving Feedback

There was a difference in the frequency with which male and female respondents report asking for feedback, with women asking more frequently (Always/Most of the time 94.1% versus 78.6%, p = 0.07; OR 5.61, p = 0.04). More female respondents, compared to males, also preferred to receive constructive feedback in written form than male respondents (Strongly agree 22.2% vs 7.5%, p = 0.05; OR = 4.18, p = 0.009).

There was no difference by gender in preference for receiving general or positive feedback face-to-face versus in written form, nor in a group versus individual setting.

Giving Feedback

Men, compared to women, more often preferred to give general (Strongly agree: 74.7% vs 54.7%, p = 0.03; OR NS) and constructive (Strongly agree: 58.9% vs 43.4%, p=0.003; OR NS) feedback face-to-face. Conversely, more women preferred to give general feedback in written form (Strongly agree/Agree: 67.3% vs 49.5%, p=0.04; OR 4.98, p =0.003).

More male respondents, compared to females, agreed with being comfortable with (Strongly agree: 38.5% vs 30.2%, p=0.03; OR = 10.21, p =0.003) and liking (Strongly agree: 36.3% vs 26.4%, p = 0.15; OR = 4.40, p = 0.04) to give constructive feedback.  Men reported more frequently discussing learner weaknesses (Always/Most of the time/Sometimes: 92.1% vs 78.4%, p =0.03; OR NS).

We found no gender difference in response to whether feedback was altered based on the gender of the recipient, with only 27(16.5%) respondents agreeing that they made some alteration in the way they give feedback.  However, of those who did report changing their approach, men were more comfortable than women in giving male recipients constructive feedback (76.5% vs 44.4%, p=0.05). 

Discussion

We observed differences in how men and women preferred to give and receive feedback at one academic medical institution, with men preferring face-to-face contact while women preferred written comments, a difference that was most pronounced with constructive feedback.  These differences persisted after controlling for age, stage of training, and department. Our respondents were more hesitant to give constructive feedback to female recipients and more comfortable giving constructive feedback to male recipients. Of those who admitted to changing their approach to feedback based on the gender of the recipient, they gave women more positive feedback and men more constructive feedback.  These findings are similar to those previously described in the business literature (Brewer et al., 1996). To our knowledge, this is the first description of this in a medical education setting.

We also found that women asked for feedback more frequently than men.  Previous studies have demonstrated that men and women differentially ask for feedback based on the gender composition of the group and the task at hand (London, Larsen, & Thisted, 1999; Miller & Karakowsky, 2005). The clear preference that male respondents showed for giving feedback, especially constructive, face-to-face may be explained by their greater comfort in giving such feedback.  Our results are consistent with previous studies indicating that men are more likely to give corrective feedback more frequently and sooner than female counterparts (Brewer et al., 1996). Best practices for feedback content indicate that a mix of positive/reinforcing and constructive feedback is optimal, and that receiving positive reinforcement alone does not improve performance as well as specific feedback on deficiencies (Boehler et al., 2006; Brinko, 1993).

The differences we found in the preference for written versus oral feedback between women and men needs to be further explored, but feedback may be better received if given in the preferred mode for the learner, as there is not clear evidence that one is superior to the other (Bing‐You, Greenberg, Wiederman, & Smith, 1997; Elnicki, Layne, Ogden, & Morris, 1998; Veloski, Boex, Grasberger, Evans, & Wolfson, 2006). Knowing and acknowledging this may help with faculty development in encouraging a variety of modes of feedback or even asking the preference of the learner.

The generalizability of the findings of this study is limited by the survey design which could be influenced by recall bias as well as the possibility of sampling error due to the self-selected, small sample that may have already been biased towards the importance of feedback. This study also took place at a single institution, and local culture may play a role in attitudes, expectations, and skills related to feedback.

Conclusion

With more interactions occurring across gender between clinical faculty and learners, differences in how men and women give and receive feedback need to be further studied and addressed.  There is a paucity of literature in medical education on the relationship between gender and attitudes, expectations, and skills around feedback.  This study adds preliminary findings that will need to be explored with future investigations.  All learners need clear, specific feedback both positive and constructive, and if the gender of the giver or recipient affects the type or content of the feedback, learners may not be receiving optimal information for future improvement.

Take Home Messages

Notes On Contributors

Dr. Jones is assistant professor, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.

Dr. Murray is professor, Department of Pediatrics, West Virginia University, Morgantown, WV.

Dr. Strader is director of online programs, School of Agriculture, West Virginia University, Morgantown, WV.

Dr. Nyachae is eLearning senior applications administrator, Information Technology Services, West Virginia University, Morgantown WV.

Dr. Khakoo is professor, Department of Medicine, West Virginia School of Medicine, Morgantown, WV.

Acknowledgements

Dr. Lesley Cottrell for help with survey development and obtaining funding.

Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number U54GM104942.

Bibliography/References

Bing‐You, R. G., Greenberg, L. W., Wiederman, B. L., & Smith, C. S. (1997). A randomized multicenter trial to improve resident teaching with written feedback. Teaching and Learning in Medicine, 9(1), 10-13.

https://doi.org/10.1080/10401339709539806   

Boehler, M. L., Rogers Da Fau - Schwind, C. J., Schwind Cj Fau - Mayforth, R., Mayforth R Fau - Quin, J., Quin J Fau - Williams, R. G., Williams Rg Fau - Dunnington, G., & Dunnington, G. (2006). An investigation of medical student reactions to feedback: a randomised controlled trial. (0308-0110 (Print)).

https://doi.org/10.1111/j.1365-2929.2006.02503.x   

Brewer, N., Socha, L., & Potter, R. (1996). Gender Differences in Supervisors' Use of Performance Feedback. Journal of Applied Social Psychology, 26(9), 786-803.

https://doi.org/10.1111/j.1559-1816.1996.tb01131.x   

Brinko, K. T. (1993). The Practice of Giving Feedback to Improve Teaching: What Is Effective? The Journal of Higher Education, 64(5), 574-593.

https://doi.org/10.2307/2959994   

Chowdhury, R. R., & Kalu, G. (2004). Learning to give feedback in medical education. The Obstetrician & Gynaecologist, 6(4), 243-247.

https://doi.org/10.1576/toag.6.4.243.27023   

Diana M. Lautenberger, Dandar, V. M., Raezer, C. L., & Sloane, R. A. (2014). The state of women in academic medicine: The pipeline and pathways to leadership. Retrieved from Washington, DC: https://www.aamc.org/members/gwims/statistics/   

Elnicki, M. D., Layne, R. D., Ogden, P. E., & Morris, D. K. (1998). Oral Versus Written Feedback in Medical Clinic. Journal of General Internal Medicine, 13(3), 155-158.

https://doi.org/10.1046/j.1525-1497.1998.00049.x   

Ende, J. (1983). Feedback in clinical medical education. (0098-7484 (Print)).

https://doi.org/10.1001/jama.1983.03340060055026

Evans, C., & Waring, M. (2011). Student Teacher Assessment Feedback Preferences: The Influence of Cognitive Styles and Gender. Learning and Individual Differences, 21(3), 271-280.

https://doi.org/10.1016/j.lindif.2010.11.011   

Hewson, M. G., & Little, M. L. (1998). Giving Feedback in Medical Education: Verification of Recommended Techniques. (0884-8734 (Print)).

https://doi.org/10.1046/j.1525-1497.1998.00027.x   

London, M., Larsen, H. H., & Thisted, L. N. (1999). Relationships between Feedback and Self-Development. Group & Organization Management, 24(1), 5-27.

https://doi.org/10.1177/1059601199241002

Miller, D. L., & Karakowsky, L. (2005). Gender influences as an impediment to knowledge sharing: when men and women fail to seek peer feedback. (0022-3980 (Print)).

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Schartel, S. A. (2012). Giving feedback - an integral part of education. (1878-1608 (Electronic)).

https://doi.org/10.1016/j.bpa.2012.02.003

Veloski, J., Boex, J. R., Grasberger, M. J., Evans, A., & Wolfson, D. B. (2006). Systematic review of the literature on assessment, feedback and physicians' clinical performance: BEME Guide No. 7. (1466-187X (Electronic)).

https://doi.org/10.1080/01421590600622665

Appendices

Table 1. Respondent and Institution Demographics
  Respondent Institution  
  Male n(%) Female n(%) Male n(%) Female n(%) P
Stage          
  Faculty 33 (60) 22 (40) 327 (68) 152 (32) 0.23
  Resident 40 (62) 25 (38) 263 (64) 149 (36) 0.75
  Student 26 (74) 9 (26) 115 (59) 81 (41) 0.09
           
Department          
  Pediatrics 17 (68) 8 (32)      
  Internal Medicine 16 (67) 8 (33)      
  Surgery 7 (58) 5 (42)      
  Family Medicine 6 (50) 6 (50)      
  Other 33 (62) 20 (38)      

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Janusz Janczukowicz - (25/03/2018) Panel Member Icon
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This paper addresses very important issues of gender-related differences in feedback giving and receiving skills. While the previous reviews aptly identify methodological issues, I would strongly suggest continuing research in this area with this particular paper being a pilot both regarding the research area and methodology. It would be extremely important to go beyond the gender dimension and look at intersecting factors (e.g. religion, ethnicity, social class, sexual orientation) that influence every moment of our education and professional activities, including feedback giving and receiving.
J.M.Monica van de Ridder - (16/02/2018) Panel Member Icon
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The authors state correctly that the topic of feedback and gender does not receive a lot of attention in medical education. Several studies on feedback that explore the differences but this is always in the context of other variables that are measured. Mostly it is not the core topic of the study. Therefore it is nice to see a study that pays attention to this specific topic.
The authors measure learners’ preferences, so in this way they explore the learner’s perceptions. In feedback it is important that perceptions are explored. Because perceptions drive behavior. However, we do not know in which way. The perception-behavior link in feedback research is not explored very well.

The authors sought to explore potential differences in attitudes of man and woman toward feedback giving and receiving, and expectations between men and woman of giving and receiving feedback. In the survey-design the authors added that they also measure knowledge of feedback.
In survey-design section the authors state they are measuring the learner’s preferences when receiving feedback and giving feedback. This leaves me with the question if it is possible to measure learner’s ‘attitude’, ‘expectation’ or ‘knowledge’ when you ask their preferences? The method section would have been clearer if (a) these four concepts would be defined, and (b) if the authors explained how attitudes, knowledge and expectations can be measured by asking learners’ preferences.

Are the results scale scores? Or did the authors only report certain items of the questionnaire? Because we do not know if certain information is left out, it is hard to ‘trust’ the results in this study. So it has consequences for the reliability of the study. Based on the description the author give the study cannot be repeated.

The question that needs to be addressed in this study is: have the different preferences consequences for the learner’s behavior? In other words, if learners receive feedback according to their preference will it change their behavior and will it make the feedback more effective? Only when we can answer this question, this study can impact faculty development.

It is good to see that attention is asked for gender and feedback, and if the key constructs in this study had been better defined and the methodology and the result section would be more transparent, the study could have added to our knowledge on this topic.
Deborah Murdoch Eaton - (16/02/2018) Panel Member Icon
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This is a good clearly written paper . the methodological flaws have been drawn out in the previous reviews eg low numbers, collation of results. It forms a good set of pilot data to allow a following study exploring these findings in more detail. Understanding what and how gender influences feedback preferences, and by implication likelihood on impact , is the next step - and should include qualitative analysis. Well done for sparking the interest .
Trevor Gibbs - (13/02/2018) Panel Member Icon
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I looked forward to reading this paper but after reading was left with a very strong "so what? " feeling. We know that feedback is frequently a missing element from effective teaching and learning; we know that formative assessment and feedback are positively received by students. So knowing if we have to re-structure our feedback mechanisms is very important.
There were a few things that worried me regarding the research methodology;
- The numbers are small and are from only one school, but I think it probably reflects a more general attitude
- Why choose a quantitative approach to something that might reflect more feelings and attitudes
- Like my co-reviewer, I was confused as to how and why the authors blended their results, sometimes just using strongly agree, sometimes adding them to the agree proportion.

I feel that this is just the beginning of a much bigger investigation, which by using qualitative approaches will give much more interesting results
Janet Lefroy - (12/02/2018)
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Thank you for this paper.
This is a worthwhile research question as feedback is an important learning method and what makes it work for whom could be better understood. Feedback is a social interaction, so it is to be expected that there might be gender differences in preferences.
The questionnaire was an amalgam of a validated survey and some newly designed questions. Since it is not a previously published instrument, could it be shown as an appendix? It would be helpful for example to see how general feedback is defined by comparison with positive feedback and constructive feedback, as this would cast light on the responses.
The response rate is noted to be low with student numbers particularly low. Respondents may not be representative of their cohorts so a repeat study would be worthwhile if a way of boosting response could be found.
The results are not presented in their entirety and not systematically. Sometimes a strongly agree response is compared male to female and sometimes both strongly agree and agree were combined and compared. One result reported the combined figures for always/most of the time/sometimes and compared male and female. The way the results are reported gives the impression that females had a preference for written feedback when it was actually only 22.2% who strongly agreed that they preferred written feedback, and we are not told how many agreed.
A follow-on qualitative study of these preferences would be informative so that the social dynamics in the feedback process could be better understood. Best wishes with your research.
P Ravi Shankar - (12/02/2018) Panel Member Icon
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Thank you for the opportunity to review this interesting manuscript. I have long been interested in the impact of increasing number of women entering the profession of medicine. This is a phenomenon which is seen throughout the world.
The low response rate is one of the limitations of the study. A response of around 20% is however, not uncommon in electronic surveys. I would be interested in knowing the statements which the authors used to obtain information on respondents’ preferences while giving and receiving feedback. The authors can expand the results section. I will also be interested in the respondents’ free-text responses. I do agree with the authors that further studies should be conducted in other institutions and other locations. The results could have implications on the process of giving and receiving feedback. The authors can provide take home messages. This article will be of interest to medical educators but can be further strengthened based on the suggestions provided above.