How to Deliver Effective Feedback to Your Trainees

October 2, 2014 at 12:10 am


Patricia A. Kritek, MD, EdM

It’s easy to assume that doctors have the background necessary to provide feedback to their trainees; however, the skills of planning, observing, and delivering feedback are rarely taught in medical school. As a consequence, trainees are often given inadequate feedback, and the experience for both the teacher and trainee can become frustrating.

To improve the quality of feedback and the trainee’s chances of success, the teacher must build a culture of feedback, says Patricia A. Kritek, MD, EdM, associate professor in the Division of Pulmonary and Critical Care Medicine and medical director of critical care at the University of Washington Medical Center in Seattle.

In this Q & A, Dr. Kritek shares how to establish a culture of feedback, so that you may begin to grow the skills necessary to pass along your knowledge quickly, concisely, and comfortably.

Q: What are the preparations for creating a culture of feedback?

A: Set expectations and goals. From the start, teachers must be upfront about their expectations of a trainee’s roles and responsibilities. This helps the trainee avoid being surprised by feedback if there are times when these expectations are not met. In the same conversation, teachers should hear what the trainee wants to get out of the experience as well and work to establish mutual goals.

Expectations should include bidirectional feedback. It can’t be only be the teacher giving feedback—the trainee should be able to give feedback as well. Honest bidirectional feedback is hard to achieve, because the trainee may be worried about grading or evaluations. But if you set the expectation that it’s bidirectional, you contribute to creating a safe environment in which you can both deliver and receive feedback.

When setting goals with the trainee, it’s important to note their priorities. They may want to work on presentations or a particular procedural skill. If they are able to express that to you, you will know to keep your eyes and ears open when the opportunities arise to focus observations and provide constructive feedback on those skills.

Q: What is “intentional observation”?

A: You can work with someone for a long time and not have any specific, tangible, behavioral feedback if you don’t look for it. This is why intentionally observing and gathering data is important. Intentional observation requires a little bit of metacognition. This can be challenging because you may be involved in patient care or immersed in another activity, but teachers must step back from time to time and thoughtfully analyze the trainee’s actions.

Q: What kind of data should be gathered?

A: The data that you gather needs to be thorough enough to meet the minimum of effective feedback, which is that it should be:

  • specific,
  • focused on behaviors,
  • honest,
  • balanced,
  • timely,
  • and well-timed.

To give specific feedback, you may want to take notes on specific actions or behaviors that you want to reflect back to the trainee when you meet. Vague feedback can’t be applied to the next experience. Have a specific example, whether it’s a word someone used, the situation, or procedure. It’s hard to remember the specifics later, so write them down as they occur.

Behaviors have the potential to be modifiable. Personality traits, on the other hand, are not easily changed. But personalities will manifest in specific behaviors that are—as stated earlier—potentially modifiable. If the trainee has a certain interaction style that you think is ineffective, ask yourself: “What is the behavior that I’m reacting to, and how can it be modified so that the trainee will do better next time?”

Honesty comes in the form of direct, constructive feedback. It’s common for a teacher who is uncomfortable with giving constructive feedback to be misunderstood by the trainee. While the feedback shouldn’t be a hurtful or mean, the teacher needs to be straightforward to ensure that the trainee complete understands what she can work on.

Balanced feedback is achieved by providing both positive and constructive feedback. That does not mean for every one good thing, you must say one bad thing, or vice versa. But the trainee will listen to constructive feedback if there’s also reinforcement of the things that he is doing well because it’s not all about what he did wrong. This helps the teacher establish a safe environment.

Positive feedback is more than saying “great job.” Instead, this should be reinforced by giving the trainee specific examples. You might say: “When you did Ms. Jones’s neurological exam, the degree of detail that you did in that exam was perfect, and it showed that you knew that was a priority of what was going on with her.”

The same goes for providing constructive feedback. You might say: “When you met with Mrs. Smith’s family and talked about changing our goals of care, some of the language you used was not as effective, specifically: X, Y, Z.”

“Timely” means that the feedback is provided at a point when the trainee can digest it and has enough time to correct or reinforce the behavior. “Well-timed” is when the feedback is presented at the appropriate moment, particularly if it’s on an emotional topic. When a patient dies, for example, it’s appropriate to wait and find a less-emotional time and protected space to give the feedback.

Q: When should feedback be delivered?

A: Often it’s appropriate to give feedback in the moment. However, if it’s more challenging, summative feedback that will take place mid-rotation or at the end of rotation, it is necessary to schedule adequate, protected time in a quiet area so that you can have an open and honest conversation without the distraction of pages or the fear of other people listening in.

Plan the discussion ahead of time, and before the meeting, prioritize the most important points you want to make. Particularly when you have a trainee with multiple deficiencies, it’s easy to come up with a laundry list of all the things that she has done wrong. But as individuals, we can only take in two or three big points when receiving feedback. So, it’s important to focus on the salient points.

Q: What is the best approach to delivering the feedback?

A: Teachers encounter bad experiences when trainees aren’t expecting or prepared for feedback, and there are also those times when trainees don’t realize that they are receiving feedback. A gold standard is identifying the nature of the conversation before you begin delivering feedback. These conversations can begin simply enough with “I’m going to give you feedback.”

Once you’ve identified the nature of the conversation, you are ready to employ what I call the “Ask—Tell—Ask” approach.

Begin asking the trainee how he thought the rotation, bronchoscopy, family discussion, presentation—or whatever it is—went. Focus on listening and encourage a little bit of reflection on the part of the trainee. Many trainees are more critical of themselves than we are of them, and often they’ll come up with a lot of the things that we had on our lists.

After thoughtfully listening to the trainee, tell her your thoughts—again—using feedback that is specific, focused on behaviors, honest, and balanced.

Once the trainee has had a chance to process the feedback, ask her how he will modify his behaviors and do things slightly differently next time to improve her performance.

The key to success is making sure that the process of providing feedback occurs on a regular basis. As you continue this cycle, the trainee will be better educated, equipped to quality deliver care, and more likely to instill a culture of feedback in her trainees for years to come.

Dr. Kritek is a member of the ATS Medical Education Work Group and Trainee Committee, and was the featured presenter in the ATS Assembly on Behavioral Science and Health Services Research Medical Education Working Group webinar “Giving Effective Feedback: Moving Beyond the Feedback Sandwich.”


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