American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tips to give—and receive—feedback

From the May 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

Atlanta—When Nicholas H. Fiebach, FACP, informally surveyed a group of potential chief residents, he was surprised by their views of feedback as a teaching tool. While six out of seven considered feedback an important part of their teaching role, only three out of seven felt comfortable giving it.

At an Association of Program Directors in Internal Medicine workshop just before Annual Session, Dr. Fiebach, director of general internal medicine at Bayview Medical Center in Baltimore, acknowledged that giving feedback can be as stressful and uncomfortable as receiving it. Nonetheless, he said that feedback is a critical teaching tool that both teaching physicians and residents need to master.

How teachers give feedback can be as important as the content, he explained, so teaching physicians need to develop interpersonal as well as medical skills. “Sometimes a simple change, like using the pronoun ‘we’ can make the difference” between ineffective and effective teaching, he said.

Before criticizing someone, he said, teachers should describe exactly what they expect of learners and communicate goals up front. Criticizing residents for taking more than a half hour to see patients in follow-up visits will mean nothing if they were never given a time limit.

Learners should know when feedback is coming, Dr. Fiebach emphasized. If they are more knowledgeable about the process, he said, they are better prepared to receive feedback during meetings and at appropriate “on the spot” moments.

Making feedback work

Dr. Fiebach described several characteristics of effective feedback:

  • Specificity. Feedback should focus on a learner’s skills, and not on personalities or behaviors. Teachers should focus on how those skills are acquired and used and use examples from recent experiences.

  • Frequency. Two varieties of feedback will help most medical learners better absorb and reflect on the critiques they receive, Dr. Fiebach said. Formative feedback should be given daily, especially during morning reports or at the end of rounds. Summative feedback should occur annually as part of a formal, comprehensive review process.

  • Timing. Avoid offering feedback when the learner is busy, distracted or under pressure from other demands of the job. “Give feedback when someone can take it in,” Dr. Fiebach said. “The sooner in relation to the learning activity, the better.” The end of the day or workweek, or at a mutually agreed appointed time, is best, he said.

  • Types of comments. Dr. Fiebach noted that residents most often complain that they receive no positive feedback. He suggested offering a “feedback sandwich” of positive, then negative, then positive feedback. The first comments set up the listener to be receptive and attentive. The negative feedback that follows should be couched so it offers an opportunity to correct errors. The final positive feedback should encourage the learner’s active participation and follow-up.

  • Reaction. Dr. Fiebach advised soliciting the learner’s response as you give feedback. Does the learner agree or disagree with your comments? Why? What would the learner advise a physician who received similar feedback to take from the situation? Again, Dr. Fiebach noted, the goal is to get the learner to actively participate in the learning process.

  • Action. The teacher should always end the feedback session with a list of suggested activities, articles, books or other studies that the learner can use to assimilate the feedback. To advance the process, schedule follow-up meetings to discuss the learner’s progress and to share continued feedback, Dr. Fiebach advised.

  • Presentation. Some teachers lack the self-awareness to present feedback in the most effective form, Dr. Fiebach said. It might be helpful to have someone videotape a role-playing session in which you practice giving feedback. Alternately, you could ask a disinterested third party you trust to review your criticism-giving techniques.

Receiving feedback

Learners often say they crave feedback, Dr. Fiebach noted, but few are as ready to receive it as they’d like to believe. He listed several skills that learners can develop to make the most of feedback.

  • Focus on specifics. Don’t be satisfied with hearing “Great job!” from your teacher, Dr. Fiebach said. Ask for specific experiences from the morning reports, he suggested, or other examples from the day that highlight what you did right. Emphasize your willingness to receive specific advice that will further improve your performance.

  • Get descriptive. Don’t accept generalities. Ask for particular examples—both current and historical—that illustrate best-practices medicine, Dr. Fiebach said.

  • Distinguish subjective and objective. Learn to recognize and separate facts from opinions. Both subjective and objective data can be important in medicine, he said, but you must first know how to distinguish the two.

  • Don’t get defensive. While teachers should present feedback in an acceptable way, learners must accept and incorporate the feedback.  Not going on the defensive when you receive criticism “is probably the hardest thing,” Dr. Fiebach said.

  • Remedy errors. Form an action plan to correct mistakes that were pointed out to you. Without such a plan, criticism is of little use. Dr. Fiebach advised focusing your attention on remediable behaviors and feasible solutions.

  • Limit feedback. Be prepared to ask for time to reflect on feedback, assimilate salient points and correct problems.

  • Right time, right place. Work with teachers to establish a venue in which feedback can be effectively delivered and received, Dr. Fiebach said.

William Hoffman is a freelance writer in Fairfax, Va.

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