Personal view or opinion piece
Open Access

Thank you for your feedback? An imperative to improve feedback givers' skills

Alex Moroz[1], Kristin Carmody[1]

Institution: 1. New York University School of Medicine
Corresponding Author: Dr Alex Moroz ([email protected])
Categories: Assessment, Teachers/Trainers (including Faculty Development), Postgraduate (including Speciality Training)
Published Date: 05/03/2018

Abstract

Development of feedback-giving skills is an underexplored area of medical education delivery and scholarship. In addition to deepening our understanding of developing the feedback-giving knowledge, attitudes, skills, and habits necessary for providing meaningful and impactful feedback, scholarly exploration of feedback giving skills may allow us to take another step towards improving physicians’ performance, and ultimately better patient care. 

Keywords: feedback; faculty development;

Call to Action

We are mid-career clinicians and educators directing a specialty residency and a sub-specialty fellowship programs. After meeting as classmates in the Master of Health Professions Education program, we developed a shared interest in feedback within the graduate medical education context. Our thesis projects separately explored experiences of faculty who received feedback from residents (Carmody, Walia, Coneybeare, & Kalet, 2017), and residents who received feedback from faculty (Moroz, Horlick, Mandalaywala, & T Stern, 2017). Despite our subjects’ varied specialties, experience, and positions, there was a shared belief among the feedback recipients (FR) that feedback givers’ (FG) skills matter, and that FG are often unprepared for the task. The thoughts on this were, in fact, so similar across our two studies that we suspected you may have difficulty attributing the voices accurately (Table 1).

 

This Quote

Belongs to?

1. “the ___, I feel like they are very busy and they’re not so in tune with what type of feedback to give back”

a) Resident

b) Faculty

2. “how do you even know how to give feedback, right?  Like the ___ aren't like taught how to do this.  Right?  So they haven't been trained to do that. I don't think they're undergoing any kind of training about how to give feedback”

a) Resident

b) Faculty

 

3. “that’s what we should be seeking to nurture most- to teach people how to do that”

a) Resident

b) Faculty

4. “I think, again, it's important that the ___ kind of know what this is about and try to- the important part is a conversation, and be, you know, I think talk to certain people about this, about the training,  because not everyone knows how to give feedback or give negative feedback ...”

a) Resident

b) Faculty

5. “the ___ should be trained on how to give feedback and what’s good feedback”

a) Resident

b) Faculty

6. I think there probably does need to be some very basic education on what good feedback is, how it looks, how it should be done

a) Resident

b) Faculty

Table 1. Is this a faculty or a resident quote? (Answer Key: 1a, 2b, 3b, 4a, 5a, 6b)

 

A review of the literature confirmed that development of FG skills is an underexplored area of medical education delivery and scholarship. While several brief FG skill development activities have been described, others argued that unitary sessions teaching the skills of feedback provide superficial and ineffective learning (Henderson, Ferguson-Smith, & Johnson, 2005; Krackov, 2013). Although addressing both the skill and the underlying attitude informing its application longitudinally and iteratively and using different forms of feedback delivery (Henderson et al., 2005; Krackov, 2013) makes sense, we recognize that the evidence supporting this suggestion is lacking. Similarly, we were not able to find scholarly exploration of either rigorous assessment or teaching of the knowledge, attitudes, skills, and habits that are necessary for providing meaningful and impactful feedback.

On the other hand, faculty from both university-based and community-based, university-affiliated residency programs described having minimal training and a lack of understanding of the best practices for delivering feedback(Kogan et al., 2012), despite the availability of excellent practical guides(Lefroy, Watling, Teunissen, & Brand, 2015; Sargeant et al., 2018).

We share the following values, which together support the need for the medical education research community to zoom in on developing such knowledge, attitudes, skills, and habits in feedback givers:

  1. Highly performing physicians contribute to better patient care,
  2. Deliberate practice and meaningful feedback improve physicians’ performance,
  3. Skilled FG provide meaningful feedback that leads to change in practice,
  4. FG skill is only one of multiple factors that determine acceptance and impact of feedback; however, this important factor has not been addressed.

We therefore challenge our readers (and ourselves) to do just that. We envision a program of research that has cycles of FG assessment, FG training, and program evaluation. Conceptually, such a program may fit within the framework of design-based research, or follow one of the several available instructional design models.

We believe that regardless of the conceptual framework used, the first step can be a synthesis of the ample available evidence on what makes feedback effective in order to develop a FG assessment rubric. Rubrics can enhance reliable scoring of FG performance assessments, especially if they are analytic, topic-specific, and complemented with exemplars and rater training (Jonsson & Svingby, 2007). Additionally, although rubrics may not facilitate valid judgment of performance assessments per se, they have the potential of promoting learning and improve instruction of FG by making expectations and criteria explicit, which also facilitates feedback and self-assessment.

We further believe that in addition to deepening our understanding of developing the FG knowledge, attitudes, skills, and habits necessary for providing meaningful and impactful feedback, this undertaking may allow us to take another step towards improving physicians’ performance, and ultimately better patient care. 

Take Home Messages

Notes On Contributors

Alex Moroz is an Associate Professor of Rehabilitation Medicine, a Vice-Chair for Education, and a Residency Program Director at the New York University School of Medicine.

Kristin Carmody is an Associate Professor of Emergency Medicine, a Vice Chair for Academic Affairs and Education Innovation, and Co-Director of Emergency Ultrasound Fellowship at the New York University School of Medicine.

Alex and Kristin received their Master in Health Professions Education degrees from Maastricht University in 2017.

Acknowledgements

Bibliography/References

Carmody, K., Walia, I., Coneybeare, D., & Kalet, A. (2017). Can a leopard change its spots? A mixed methods study exploring emergency medicine faculty perceptions of feedback, strategies for coping and barriers to change. New York University School of Medicine.   

Henderson, P., Ferguson-Smith, A. C., & Johnson, M. H. (2005). Developing essential professional skills: a framework for teaching and learning about feedback. BMC Medical Education.

https://doi.org/10.1186/1472-6920-5-11   

Jonsson, A., & Svingby, G. (2007). The use of scoring rubrics: Reliability, validity and educational consequences. Educational Research Review.

https://doi.org/10.1016/j.edurev.2007.05.002

Kogan, J. R., Conforti, L. N., Bernabeo, E. C., Durning, S. J., Hauer, K. E., & Holmboe, E. S. (2012). Faculty staff perceptions of feedback to residents after direct observation of clinical skills. Medical Education, 46(2), 201–215.

https://doi.org/10.1111/j.1365-2923.2011.04137.x   

Krackov, S. (2013). Feedback Workshop. In J. A. Dent & R. M. Harden (Eds.), A Practical Guide for Medical Teachers (4th ed., pp. 330–331). London.   

Lefroy, J., Watling, C., Teunissen, P. W., & Brand, P. (2015). Guidelines: the do's, don'ts and don't knows of feedback for clinical education. Perspectives on Medical Education, 4(6), 284–99.

https://doi.org/10.1007/s40037-015-0231-7   

Moroz, A., Horlick, M., Mandalaywala, N., & T Stern, D. (2017). Faculty feedback that begins with resident self-assessment: motivation is the key to success. Medical Education.

https://doi.org/10.1111/medu.13484   

Sargeant, J., Lockyer, J. M., Mann, K., Armson, H., Warren, A., Zetkulic, M., … Boudreau, M. (2018). The R2C2 Model in Residency Education. Academic Medicine.

https://doi.org/10.1097/ACM.0000000000002131

Appendices

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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Tan Nguyen - (07/03/2018) Panel Member Icon
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The call to action identified is not new, given there is considerable published work in the area. It is not too uncommon that there is poor communication between the expectations for the role of the clinical educators and the student learners. In addition, institutional driven mandate to provide feedback may not necessarily be appropriate for the purpose of asssessment and therefore learning. eg. is it formative or summative or both? A multi-source feedback approach would assist to inform the issues identified in the paper.
Tripti Srivastava - (06/03/2018) Panel Member Icon
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Feedback in medical education is much researched and sparingly practised. The authors have put forth a personal viewpoint about the importance of research focus on feedback giving skills which is one of the essential factors that determine the acceptance and impact of feedback. The envisioned program of research comprising of cycles of Feedback givers assessment, its training and program evaluation is put forth for further exploration. The authors,as a part of their Master's program, observed that feedback givers (denoted as FG) do not have the necessary knowledge and skills required for giving feedback, As such, this is not an isolated observation, rather; a much widely addressed issue in medical education. A suggested model of feedback assessment rubric would've been a worthwhile exercise here.
Neil Grunberg - (06/03/2018)
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Feedback-giving (FG) skills certainly are important and need to be developed to be effective and valuable for the recipient of the feedback. This article brings attention to this need for which the authors should be complimented. The authors, however, do not go far enough. FG skills need to be developed in all health providers to include residents, faculty, more senior physicians, medical students, nurses, dentists, psychologists, and so on. FG skills are important to provide information to colleagues, peers, subordinates, “superiors,” patients, and patients’ families. FG skills are critical to optimize health care and communication among health team members. Although the authors correctly note the limited attention to FG skills in the medical education literature, there is an extant psychology literature relevant to communication.
J.M.Monica van de Ridder - (05/03/2018) Panel Member Icon
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The authors make an excellent point in their commentary that feedback giving skills are an underexplored area. The attention for feedback providing has improved over the last twenty years, - especially compared with the attention for feedback seeking, and feedback reception and perception – still it does not receive a lot of attention. Especially systematic research on training of feedback is lacking. One course does not make the difference.
It is good to see the call for action to focus on feedback giving. It would be interesting if the authors were more specific about what skills, attitudes, and knowledge in relationship to feedback provider skills in their opinion would need more attention.
The authors state that there is lack of understanding of the best practices for feedback. This is probably not only because there is not published a lot on the underlying evidence of feedback providing practices, but also because we do not know yet what the best practice is when it comes to feedback. As described by the authors, the effectiveness of feedback (feedback leading to an improvement of knowledge, skills, competence, or a positive change of attitude) it is not only dependent on the phase of feedback providing and the feedback provider, but also on the learner’s task performance, task observation and the learner’s feedback perception (1)
Because of the interaction of these variables it is hard to determine what the best practice is. It is the question if a best practice ever will be found.
This commentary might provide direction for those involved in feedback research.
1. van de Ridder JM, McGaghie WC, Stokking KM, ten Cate OT. Variables that affect the process and outcome of feedback, relevant for medical training: a meta-review. Medical education. 2015;49(7):658-73.