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Providing Effective Feedback. Faculty Professional Development Series Perelman School of Medicine September 8, 2011 Jennifer R. Kogan, M.D. Lisa M. Bellini, M.D. Department of Medicine. Workshop Objectives. Define feedback Recognize importance of feedback Identify barriers to feedback

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providing effective feedback

Providing Effective Feedback

Faculty Professional Development SeriesPerelman School of MedicineSeptember 8, 2011

Jennifer R. Kogan, M.D.

Lisa M. Bellini, M.D.

Department of Medicine

workshop objectives
Workshop Objectives
  • Define feedback
  • Recognize importance of feedback
  • Identify barriers to feedback
  • Discuss characteristics of effective feedback
  • Practice providing feedback using the Ask-Tell-Ask method
feedback definition
Feedback: Definition

“Specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance.”

“Feedback is an assessment for learning rather than an assessment of learning.”

Van der Ridder MJM, Med Educ 2008;42:189-97.

feedback vs evaluation

Conveys information


Current performance


(verbs & nouns)

Foster learning


Conveys judgment


Past performance

Normative statements

(adjectives and adverbs)


Feedback vs. Evaluation
how do people become experts
How Do People Become Experts?
  • Deliberate practice
    • Working on well defined tasks
    • Informative feedback
    • Repetition
    • Self-reflection
    • Motivation
    • Endurance

Ericsson KA et al. The role of deliberate practice in

the acquisition of expert performance. Psych Rev.1993. 100(3):363-406.

miller s pyramid
Miller’s Pyramid




trends in medical education 2000 present
Trends in Medical Education2000-present
  • Structure/Process
  • Content
    • Knowledge acquisition
  • Idiosyncratic
  • Single subjective measure
  • Norm referenced evaluation
  • Emphasis on summative

Fixed length, variable outcome

Competency Based


  • Competency Based
  • Outcome
    • Knowledge application
  • Intentional practice
  • Multiple objective measures
  • Criterion referenced
  • Emphasis on formative

Variable length, fixed outcome

Caraccio et al 2002

trends in medical education 2000 present1
Trends in Medical Education2000-present

See one, do one, teach one

  • Effective Supervision
  • Helps trainees gain skills faster and behavior change more quickly
    • Relationship quality affects effectiveness
  • Self-supervision not effective
  • Better supervision associated with improved patient safety and quality of care

Patient Safety

Increased supervision

Kilminster; Med Teach 2007

“. . . closer supervision leads to fewer errors, lower patient mortality, and improved quality of care. . . These recommendations are designed to ensure that we better train today’s residents so they can better treat tomorrow’s patients.”


Common Program


Which of the following individuals said the

following: “You can observe a lot just by watching?”

  • Sir William Osler
  • Hippocrates
  • Abraham Flexner
  • Lawrence Peter Berra
  • Lower Merion School District Administration
  • Benjamin Franklin
Which of the following individuals said the

following: “You can observe a lot just by watching?”

  • Sir William Osler
  • Hippocrates
  • Abraham Flexner
  • Lawrence Peter Berra
  • Lower Merion School District Administration
  • Benjamin Franklin
benefits of feedback learners
Benefits of Feedback: Learners
  • Develop expertise
    • identify strengths/weaknesses without academic penalty
    • practice and improve knowledge and skills
    • define teachers’ expectations
benefits of feedback teachers
Benefits of Feedback: Teachers
  • Strongly associated with teaching ratings
  • Actively recognize student progress and achievement
  • Evaluate and modify coursework/teaching
clinical education without feedback
Clinical Education Without Feedback
  • Missed learning opportunities
  • Learner insecurity about abilities
  • Inaccurate perception of performance
    • Disappointment and surprise with final evaluations
  • Time constraints
  • Limited information about learner performance
  • Absence of standards of competence
  • Inadequate knowledge of tenets of effective feedback
  • Giving negative feedback
    • Concern about undesirable consequences for learner (self-esteem)
    • Concern about undesirable consequences for teacher
What are Principles of

Effective Feedback?

principles of effective feedback
Principles of Effective Feedback
  • Related to agreed upon goals
  • Specific
  • Reinforce positive outcomes and behaviors
  • Provide guidelines for improvement
  • Quantity regulated, limited to remediable behaviors
  • First hand, objective information
  • Timely
  • Descriptive not evaluative language
  • Accompanied by explanations
  • Includes an action plan

Ende J. JAMA. 1983; 250: 777-781



Post-rounds counseling

Discharge instructions

ED encounters

Part of admission

Family meeting



First 5 minutes of encounter

Part of physical exam


the new feedback sandwich
The New Feedback Sandwich




Konopasek L 2009;

New York Presbyterian

set the stage
Set the Stage
  • Establish goals upfront: yours & the learners
  • Establish expectation of continuous feedback
  • Create environment conducive to feedback
    • Private, quiet, close to event, not post-call
  • Use the “F” word
    • Start session by telling learner: “This is your feedback”
  • Ask learner to assess own performance
    • Begins a conversation – an interactive process
    • Assesses learner’s level of insight and stage of learning
    • Promotes reflective practice
  • Tell what you observed
    • Include both positive and corrective elements
      • “I observed….”
  • React to the learner’s observation
    • Feedback on self-assessment
  • Provide action plan (suggestions for how to improve)

** Remember: limit constructive feedback to no more than 2-3 (max 4)

ask again
Ask (again)
  • Ask about recipients understanding and strategies for improvement (action plan)
    • What could you do differently?
    • Give own suggestions
  • Commit to monitoring improvement together
benefits of ask tell ask
Benefits of Ask-Tell-Ask
  • Learner centered
  • Active and interactive
  • Avoids assumptions or judgment
  • Promotes reflection
  • Branch J et al. Feedback and Reflection: Teaching Methods for Clinical Settings. Acad Med. 2002;77:1185-8.


a model of feedback
A Model of Feedback
  • Where am I going (What are the goals)?

* “feed-up”

  • How am I going (What progress is being made toward the goal)?

* “feed back”

3) Where to next (What activities need to be undertaken to make better progress)?

* feed forward”

Hattie and Timperley. Review of Educational Research. 2007;77:81-112.

scenario 1
Scenario #1


You have been working with a medical students for four days.

The medical student is enthusiastic, hard working and

interested in learning. The student seems to enjoy working

with patients, is timely and is always asking to see additional

patients. You are concerned that the student is having

difficulty presenting a coherent, organized history and

physical exam and have noticed that the student's notes are

similarly disorganized with an incomplete assessment and

plan. You believe the student's knowledge base is borderline.

scenario 11
Scenario #1

Medical student

You are four days into your rotation. It is your second core

clerkship. You think that you have been doing a good job. You

really like seeing patients and are eager to learn. You have

tried to be enthusiastic and a team player. The office/ward

has been very busy and learning how to do a focused patient

visit has been a bit hard and you are having problems piecing

it all together.

scenario 2
Scenario # 2


It is the midpoint of your four-week rotation with a pediatric

core clerkship student. You had told the medical student at

the beginning of the rotation that you would have a mid

rotation feedback session. The medical student is very bright

and has a superior fund of knowledge. He is able to perform

a focused history and physical exam, synthesize a problem

list, assessment and plan. However, the student has arrived

late on three occasions and requested to leave early another

day. Some of the nurses felt he has been curt and abrasive.

The student once got visibly annoyed when speaking with a

nurse earlier in the week.

scenario 21
Scenario #2

Medical student

It is the midpoint of your four-week rotation and you and

your attending are meeting for a planned feedback session.

You haven't been too interested in this rotation - you are

pretty certain that you are going into Radiology. You believe

that you have done a pretty good job of seeing patients and

have tried to come up with differential diagnoses for the

patients you see. But overall, you are pretty bored and are

looking forward to your next rotation which you think will be

much more pertinent to your future career goals.


Skill/No Will

Skill and Will




No Skill/ Will

No Skill/No Will




scenario 3
Scenario #3


You are on morning rounds with your resident,

intern and medical student. The team had a very

busy night and admitted several sick patients. One

patient was admitted with dyspnea. The patient was thought

to have an asthma flare and was given nebulizers. Oxygen

saturations levels were checked throughout the night. A CXR

was not done and no oxygen was ordered. While at the

bedside you notice the oxygen saturation of 85% and the

patient in respiratory distress.

scenario 31
Scenario # 3


You have just finished a very busy call night.

You did not have time to see all of your patients

before attending rounds. You get to the bedside of

this patient and begin your presentation. As you

begin talking about the physical exam, the attending

picks up the patient flow sheet and notices the

hypoxemia. The attending enters the room to find

the patient in respiratory distress . . .

recommended reading
Recommended Reading
  • Archer JC. State of the science in health professional education: effective feedback. Mewdical Education. 2010; 44:101-8.
  • Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-81.
  • Hattie J, Timperley H. The power of feedback. Review of Educational Research. 2007;77:81-112.
  • Van de Ridder JMM, Stokking KM, McGaghie WC, ten Cate OTJ. What is feedback in clinical education? Medical Education. 2008;42:189-97.