Effective Feedback in Clinical Education

Detailed and prompt feedback on clinical performance, and opportunities to improve, are necessary to guide a trainees’ actions in the clinical setting as they work towards achieving required competencies (Krackov & Pohl, 2011). Feedback that is timely, targetted, actionable, and meaningful to the individual, helps a trainee gauge their performance and make action plans for improvement (Bing-You & Trowbridge, 2009).

However, giving and receiving feedback can be an emotionally charged process because a trainee may not understand, accept, or know how to use the feedback for improvement. Given the nature of clinical interactions, where instructors may only have limited time to engage with an individual trainee, even small pieces of informal feedback have a large impact on learning. Taking a systematic approach to feedback can help address these concerns but requires instructors to consider several important questions, such as:

– What role does feedback play in the culture of the clinical experience?
– How do I construct feedback that is impactful?
– How should I deliver the feedback to maximize understanding and usefulness?
– What actions am I taking that help or hinder the feedback process with my trainees?

To help instructors answer these questions, the following resource presents some research-based strategies on feedback in clinical settings. 

On this page

• Creating a Culture of Feedback
• Constructing Effective Feedback
• Delivering Feedback
• Reflecting on your Feedback Skills

Cite this resource: Columbia Center for Teaching and Learning (2023). Effective Feedback in Clinical Education. Columbia University. Retrieved [today’s date] from https://ctl.columbia.edu/resources-and-technology/resources/effective-feedback-clinical/

Creating a Culture of Feedback

Providing feedback should be embedded in the culture of the clinical experience, and trainees should expect this to be built into their daily training (Krackov, 2011). The more prevalent feedback is, the easier it becomes for a trainee to achieve a state of ‘reflection in action’ (Delva, 2013). Trainees tend to seek and use feedback more when they perceive it to be an inextricable part of the learning experience and when they sense that an instructor is investing in their professional development (Kluger and Denisi, 1996). Below are some specific strategies instructors can use to create a culture of feedback in the clinical setting. 

Actively create a respectful learning environment. 

A positive learning climate is essential in order for feedback to be maximally effective (Hewson & Little, 1998). Trust and respect for the instructor make a trainee more receptive to feedback (Hesketh & Laidlaw, 2002). 

To help create a respectful learning environment, an instructor might:

• Set standards for respectful discourse by modeling active listening and actively making space for everyone to participate and have their viewpoints valued. This will encourage participation by creating a more inclusive learning environment where trainees feel better speaking up.
• Recognize mistakes as part of learning, not as failures of personality. This reduces feelings of shame and inadequacy and normalizes trainees asking for help and seeking feedback.
• Seek and be receptive to feedback from trainees and address difficult or uncomfortable topics directly. This shows the trainees their viewpoints are valued and demonstrates your dedication to a respectful learning environment.

Build feedback into the structure of the clinical experience.

Deliberate practice in medical education should focus on learning outcomes, feedback, mentoring, and reflection for the achievement of curricular milestones. Regular ongoing feedback is essential to promoting a culture of continuous learning and improvement (Krackov & Pohl, 2011).

To help build feedback into the structure of the clinical experience, an instructor might:

• Make feedback a regular occurrence. Frequent, low-stakes feedback between evaluations reduces anxiety and allows for improvement.
• Build a mix of formal and informal feedback into the structure of the learning experience.

• • A brief, informal formative feedback session can take place immediately or as soon as possible after the observation of a behavior, when both instructor and trainee recall the events accurately.
  • Longer formal feedback sessions can be scheduled at regular intervals throughout the course/rotation.

Make learning goals and expectations clear to trainees.

Orienting a trainee to the goals and objectives of the learning experience and what they are expected to achieve sets the stage, makes a trainee more comfortable and responsible, and engages a trainee in their own learning (Wood, 2000).

To help make learning goals and expectations clear to trainees, an instructor might:

• Engage in explicit expectations-setting conversations that co-negotiate the role of the instructor and trainee in the learning experience and encourage trainees to be proactive in seeking feedback (Milan et al., 2011).
• Communicate goals and objectives of your feedback. When trainees are unclear of the expectations, they are more likely to view feedback as arbitrary. 

Consider a trainee as a whole person.

Feedback is more than just one person providing information to another to help them improve; feedback is part of a social interaction influenced by culture, values, expectations, personal histories, relationships, and power. Trainees carry with them different perspectives on the role of medicine in society which can impact how they engage in their medical education (Lefroy et al., 2015). Cultivating an environment that views the individual perspectives of a trainee as an asset is more inclusive and develops a trainee’s self-efficacy. 

To recognize the trainee as a whole person, an instructor might:

• Be mindful of assumptions. You may not always know what a trainee wants to learn, why they are struggling, or what information they take out of a situation or feedback conversation.
• Develop cultural competencies by acknowledging cultural and generational differences and being open to learning about other cultures. This can help you understand a trainees actions that may be based in cultural differences. 

Customize your feedback. 

The best feedback varies according to a trainee, the instructor-trainee relationship, and the context. As the trainees, patients, and contexts change, so too does the most useful approach to feedback (Lefroy et al., 2015). Every trainee comes in with different experiences, and what works for one trainee may not work for another. Perceptions of relevance and credibility of the feedback are important parameters for trainees to decide how to act on feedback and both increase when feedback is tailored to an individual’s needs (Watling et al., 2012). The more agency a trainee has in determining the type of feedback received, the more likely they are to learn from that feedback, resulting in improved actions.

To customize feedback to the individual, an instructor might:

• Tailor the feedback content and delivery based on the individual trainee and the circumstances. This will increase the likelihood that a trainee connects with the feedback. 
• Have trainees perform a self-assessment. Self-assessment requires a high level of metacognitive thought, which promotes learning. You can then engage a trainee in a reflective conversation that connects their self-assessment with your observations and elaborations.
• Ask a trainee about their goals and struggles and what they would like feedback on during their clinical experience so you can tailor your feedback to their goals. 

Constructing Effective Feedback

The basic principles of providing effective feedback are that feedback must be targeted, actionable, and meaningful to a trainee. Feedback should focus on the performance, not on the individual. Effective feedback is descriptive, rather than evaluative, and connects to a trainee’s individual needs and motivations. It should acknowledge and reinforce exemplary behavior which will give a trainee confidence in their skills, highlight areas requiring improvement, and suggest measures for improvement (Qureshi, 2017). Engaging a trainee in the feedback process by giving them a clear and explicit role ensures they see feedback as an active and ongoing process. Below are some specific strategies for constructing effective feedback that will be impactful to a trainee. 

Base feedback on direct observation. 

Feedback based on direct observation by the instructor has been reported to be more acceptable and instructive to a  trainee than feedback based on second-hand reporting (Ende, 1983; Van Hell et al., 2009). A trainee may discount feedback if they believe that the statements are based on second-hand or limited observation (Bing-You et al., 1997; Ramani & Krackov, 2012).

To provide feedback that is based on direct observation, an instructor might:

• Base feedback on observed behaviors and not on incomplete interactions. If you are not able to observe a complete interaction then it may be helpful to collect trends in a trainee’s performance over multiple observations.
• Focus on behaviors that can be changed, not the person or personality (Wood, 2000).

Give specific, balanced feedback that reinforces desired behaviors and identifies areas for improvement.

Constructive feedback is particularly beneficial when it focuses on specific performance and deals with behaviors that a trainee is able to control or modify (Bing-You, 1997; Wood, 2000). Acknowledging and reinforcing exemplary behavior supports good practices and motivates a trainee to repeat them (Cantillon & Sargeant, 2008).

To provide feedback that is targeted and specific, an instructor might:

• Give a mix of positive and negative feedback. Only focusing on negative feedback can make  a trainee feel they did not do anything right, and they might inadvertently neglect their strengths without positive reinforcement. Likewise, focusing only on positive feedback does not give a trainee a pathway to improve. 
• Give feedback that is task-specific by focusing on how a task was done and how that type of task should/might be done:
  • Reinforce actions performed well.
  • Acknowledge a trainee’s choice of approach and discuss other ways they might reach the same result without being overly prescriptive. 
  • Identify omissions or actions which might have been done better.
  • Collaboratively develop strategies for improving the quality of the work.
• Focus the feedback on the most important points so that a trainee can absorb it. (Wood, 2000; Krackov, 2009).

Ensure that feedback is actionable and provides trainees the opportunity to improve.

Creating a plan for improvement reinforces learning as a continual and ongoing process. This process should be co-negotiated as opposed to the instructor giving a trainee a list of items to accomplish. This process will help develop a trainee’s skills in reflection and instill a growth mindset in their learning (Ramani & Krackov, 2012).

To provide feedback that is actionable, an instructor might:

• Create action plans with your trainee. Trainees are unlikely to be influenced by feedback that is not followed by an opportunity for them to demonstrate improving performance. After discussing a trainee’s performance of a task, ask them to generate ideas for actions they can take to improve. You can then endorse or modify their ideas to co-construct an action plan.
• Follow up on action plans. Action plans should be constructed as an ongoing process with benchmarks that allow you and a trainee to evaluate progress.

Delivering Feedback

When and how feedback is delivered is just as important as the content of the feedback. Trainees often have more negative emotions to how feedback is delivered than the content of the feedback. It is important to consider ways feedback delivery can be direct and corrective feedback while also reducing feelings of shame and judgment. Below are some specific strategies instructors can use to determine the best approach to delivering feedback to their clinical trainees. 

Consider the timing of a feedback delivery.

Providing feedback in a timely fashion, even if it is informal, increases the impact of the feedback on a trainee’s actions. a trainee’s memory of an event diminishes with time so feedback delivered too long after the clinical experience may not be effective at producing improvements in a trainee’s behaviors (Bing-You et al., 1997). However, giving feedback immediately after an event may not be beneficial if that event was stressful or emotional.

To deliver feedback in a timely way, an instructor might:

• Deliver positive feedback quickly. It can be given, gently, in the moment. This can increase the self-efficacy of a trainee and highlight exemplary behaviors for the other trainees in the room. 
• Deliver negative feedback in private to reduce feelings of shame and discomfort. 
• Consider the best time to give feedback based on a trainee, and the circumstances (Lefroy et al., 2015). 

Consider the language, tone and body language used during the session.

The wording and tone of feedback significantly impacts what a trainee takes from it. When emotions are running high, feedback can come across as more negative and less supportive than intended. 

When considering language and tone of feedback, and instructor might:

• Use a respectful, supportive tone and precise, descriptive, neutral wording.
• Use motivating language that emphasizes struggle as part of the learning process when discussing strategies for improvement.
• Consider the message sent by body language. For example, sitting down with a trainee can feel more casual and minimize the perception of discipline and judgment.

Confirm a trainee understands your feedback.

Trainees may not internalize feedback for a number of reasons. It is the instructor’s responsibility to ensure that the message of the feedback reaches a trainee in a meaningful way. 

To confirm a trainee understands the feedback provided, an instructor might:

• Indicate whether feedback is necessary for a trainee to reach minimal standards or whether the feedback is intended to build upon an already adequate performance. (Ramani & Krackov, 2012). 
• Have a trainee summarize your feedback and give them space to explain their thoughts and reasoning for their actions. 

Reflect on your Feedback Skills 

Feedback is a skill, which can be acquired and honed through repeated practice (Cantillon & Sargeant 2008). Even successful feedback interactions will benefit from the process of reflection to help assure that future meetings also turn out well. Making reflection a part of every feedback encounter will improve the instructor’s skills at giving feedback.

To engage in reflective practice around feedback, an instructor might:

• Reflect on your experiences following a feedback giving interaction with a trainee: what went well? What could be improved for next time? What actions will you take to make those improvements? 
• Solicit feedback on your feedback skills from trainees to further develop your feedback practice.
• Learn from colleagues by discussing your experiences giving feedback. 

Additional Resources

• American Association of Medical Colleges – Feedback Toolkit for Medical Educators 
• American Medical Association – Coaching in Medical Education: A instructor handbook

References

Bing-You RG, Trowbridge RL. 2009. Why medical educators may be failing at feedback. JAMA 302:1330–1331.

Bing-You RG, Paterson J, Levine MA. 1997. Feedback falling on deaf ears: Residents’ receptivity to feedback tempered by sender credibility. Med Teach 19:40–44.

Cantillon P, Sargeant J. 2008. Giving feedback in clinical settings. BMJ 337: a1961.

Delva D, Sergeant J, Miller S, Holland J, Brown P, Leblanc C.,2013 Encouraging residents to seek feedback. Med Teach; 35: 1625–31.

Ende J. 1983. Feedback in clinical medical education. JAMA 250:777–781.

Hewson MG, Little ML. 1998. Giving feedback in medical education: Verification of recommended techniques. J Gen Intern Med 113:111–118.

Hesketh EA, Laidlaw JM. 2002. Developing the teaching instinct: Feedback. Med Teach 24(3):245–248.

Klaber B. 2012. Effective feedback: an essential skill. Postgrad Med J; 88:187–8.

Kluger A, Denisi A. 1996. The effect of feedback intervention on performance: a historical view, a meta-analysis, and a preliminary feedback intervention theory. Psychol Bull; 119:254–84.

Krackov SK. 2009. Giving feedback. In: Dent JA, Harden RM, editors. A practical guide for medical teachers. 3rd ed. Churchill Livingstone Elsevier.

Krackov SK, Pohl H. 2011. Building expertise using the deliberate-practice curriculum-planning model. Med Teach 33(7):570–575.

Krackov SK. 2011. Expanding the horizon for feedback. Med Teach 33:873–874.

Lefroy, J., Watling, C., Teunissen, P. W., & Brand, P. (2015). Guidelines: the do’s, don’ts and don’t know’s of feedback for clinical education. Perspectives on medical education, 4(6), 284-299.

Milan FB, Dyche L, Fletcher J. 2011. ‘‘How am I doing?’’ Teaching medical trainees to elicit feedback during their clerkships. Med Teach 33:904–910.

Parkes J, Abercrombie S, McCart T. 2013. Feedback sandwich affect perceptions but not performance. Adv Health Sci Educ Theory Pract; 18:397–407.

Pendleton D, Schofield T, Tate P, Havelock P. 1984. The consultation: an approach to learning and teaching. Oxford: Oxford University Press;

Qureshi NS. 2017. Giving effective feedback in medical education 2017. The Obstetrician & Gynaecologist; 19:243–8.

Ramani, S., & Krackov, S. K. 2012. Twelve tips for giving feedback effectively in the clinical environment. Med Teach, 34(10), 787-791.

Rudolph J, Raemer D, Shapiro J. 2013. We know what they did wrong, but not why: the case for ‘frame-based’ feedback. Clin Teach; 10:186–9.

Van Hell EA, Kuks JBM, Raat AN, Van Lohuizen MT, Cohen-Schotanus J. 2009. Instructiveness of feedback during clerkships: Influence of supervisor, observation and trainee initiative. Med Teach 31:45–50.

Watling C, Driessen E, Vleuten CPM van der, Lingard L. 2012. Learning from clinical work: the roles of learning cues and credibility judgements. Med Educ. 46:192–200

Wood B. 2000. Feedback: A key feature of medical training. Radiology 215:17–19.