#421

Providing Formative Feedback in the Clinical Setting

  • Carla Khalaf McStay MD
  • Gabrielle Langmann MD
  • Robert Arnold MD

Background This Fast Fact offers practical advice about providing formative feedback to learners in clinical settings, with a special focus on palliative care. These techniques can be applied for all learners across various clinical disciplines.

Types of feedback Formative feedback is focused on a specific behavior or skill, typically occurs shortly after the learner demonstrates the skill, and is usually low stakes (e.g., not a “grade,” a judgement, or an evaluation). Think of it as the sort of information a coach would give an athlete in the moment to improve performance (“When you serve the ball, keep your elbow lower”). Summative feedback provides a more global evaluation, typically occurring at the end of a learning period, and is evaluative (“You are right on track for where 3rd year medical students should be in your patient interviewing skills”). Formative feedback given frequently throughout a learner’s clinical rotation is necessary for learners to achieve high quality performance (1,2).

Establish an environment for effective feedback At the start of a rotation, the preceptor should ask the learner for their overall goals for the learning experience (3). These goals should be attainable by the end of the rotation and they should be SMART: specific, measurable, attainable, relevant, and timely. The preceptor should review these goals and identify additional level-appropriate targets for the learner. Shared goal setting gives the learner and preceptor a common focus for the rotation (4,5). Helpful questions can include: “What are your learning goals for this rotation?” “What skills were you hoping to practice and refine during this rotation?” The preceptor should set the expectation for regular formative feedback throughout the rotation (6). Setting this expectation helps the learner know that the goal of feedback is not punitive nor evaluative, but rather given for the learner’s deliberate practice (4,7): “Like a music or sports coach, I will give you feedback after patient encounters. My goal is to help you improve your patient interviewing skills throughout the rotation.” Preceptors themselves can normalize feedback-giving by asking other interdisciplinary team members to give them feedback after a patient interaction.

A simple formative feedback model One simple model for giving feedback involves the preceptor naming one observed behavior or demonstrated skill that was effective and offering one concrete behavior or skill to try in the next encounter. E.g., “When you stayed silent after delivering the serious news, the patient was able process the information and their emotions. Next time, acknowledge their emotions before giving more cognitive information.” Each opportunity for feedback should focus on a single directly observed behavior or action, rather than a collection of behaviors, a personality trait, or a quality of the learner (8). For example, “When you utilized empathetic statements during that encounter, the family responded positively,” is more helpful to the learner than “You were very empathetic during that encounter.” (5,8,9). The best feedback describes the solution, rather than the problem, in concrete, actionable terms: “When taking a pain history, ask about the alleviating and aggravating factors of the pain is far more helpful than “You need to be more thorough with your pain history (5).

Incorporating learner self-feedback A more elaborate feedback model includes self-assessment to promote the learner’s ability to self-correct in the future without the teacher’s direct presence (4,10). To achieve this, elicit the learner’s self-assessment after each encounter through the lens of their learning goals (9): e.g., “One of your learning goals for this rotation was to become more comfortable with leading family meetings. Tell me how you thought through your response when the patient’s son said, ‘Isn’t there anything else you could try to save my dad?’” Then, give your own feedback using the simple formative model above. Finally, elicit the learner’s understanding of what was discussed by asking them for a “take-away” point: something they learned that they can apply the next time they encounter a similar situation (8): “Next time when a family member asks a seemingly cognitive question, I will try responding to emotion first.”

Special considerations for serious illness communication Feedback specific to communication skills is often challenging. The learner may “blame” the patient rather than see the opportunity for self-improvement (e.g., “The patient just doesn’t get it”). Learners may view feedback about communication skills as an evaluation about themselves as a person (e.g., “Next time, respond to emotion before giving more data” may be heard by a learner as “I am not a caring person.”). It is important to explicitly frame communication as skills which are distinct from a learner’s personal compassion or professional dedication (5,9). Educators must also recognize the potential for a learner’s emotional response to challenging cases (3,5). Emotional responses can foster learning if utilized appropriately by motivating learners to improve via an educational tension (or a “teachable moment”), but they also make it difficult to process feedback especially when emotional responses are strong. By naming the emotion and reflecting on the intensity of the clinical case (“This is a really challenging situation”) the learner’s emotional response can be normalized. Doing so can help learns attend to and focus on the formative feedback.

Summary To be most effective, formative feedback should be behaviorally based, non-evaluative in nature, and focus on the solution rather than the problem. Feedback given frequently and that follows up on goals set by the learner maximizes opportunities for deliberate practice and incorporation of new concepts and skills throughout the clinical rotation (3).

References

  1. Ende J. Feedback in clinical medical education. JAMA. 1983; 250(6):777-781.

2. Cope DW, Linn LS, Leake BD, Barrett PA. Modification of residents’ behavior by preceptor feedback of patient satisfaction. J Gen Intern Med. 1986 Nov-Dec;1(6):394-8.

3. Menachery EP, Knight AM, Kolodner K, Wright SM. Physician characteristics associated with proficiency in feedback skills. J Gen Intern Med. 2006 May;21(5):440-6.

4. Molloy E, Ajjawi R, Bearman M, Noble C, Rudland J, Ryan A. Challenging feedback myths: values, learner involvement and promoting effects beyond the immediate task. Med Educ. 2020 Jan; 54(1):33-39.

5. Jug R, Jiang XS, Bean SM. Giving and receiving effective feedback: a review article and how-to guide. Arch Pathol Lab Med. 2019 Feb;143(2):244-250.

6. Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback, and physicians’ clinical performance: BEME Guide No. 7. Med Teach. 2006 Mar; 28(2):117-28.

7. Thomas JD, Arnold RM. Giving feedback. J Palliat Med. 2011 Feb;14(2):233-9.

8. Lemov, D. Teach Like a Champion 2.0: 62 Techniques That Put Students on the Path to College. San Francisco: Jossey-Bass, 2015.

9. Srinivasan M, Hauer KE, Der-Martirosian C, Wilkes M, Gesundheit N. Does feedback matter? Practice-based learning for medical students after a multi-institutional clinical performance examination. Med Educ. 2007 Sep;41(9):857-65.

10. Lovell B. What do we know about coaching in medical education? A literature review. Med Educ. 2018 Apr;52(4):376-390.

Authors’ Affiliations: University of Pittsburgh Medical Center, Pittsburgh, PA.

Conflicts of Interest: The authors have declared no conflicts of interest.

Version History: originally edited by Drew A Rosielle MD; first electronically published May 2021