Feedback – health professional educators and learners discuss feedback regularly.  The literature on the subject is large.  Yet we still don’t seem to be able to get it right or get the outcomes we want from the feedback processes we use.

I attended an online presentation this week on feedback, which also asked the question: why after a century of research, we still can’t get it right?  The hybrid session was held at McMaster University and was given by Professor Kevin Eva of the Centre for Health Education Scholarship, University of British Columbia, Vancouver.  In this blog I summarise his thoughts and reflect on their implications.

Kevin started by acknowledging that there are many feedback models, all of which have value but warned that once they become an algorithm, they lose that value.  The ubiquitous ‘feedback sandwich, for example, consists of constructive or negative feedback sandwiched between two positive statements. 

This reminds me of the feedback model used during my GP training, sometimes referred to as the Pendleton model^*, which also starts with what was done well, followed by what could be done better/differently.  Feedback recipients don’t hear the positives because they are waiting for what they perceive as the negatives.  They are expecting ‘this was great BUT…’

To be fair, Pendleton’s model when used in small group sessions does start with asking the learner what they think what went well first, but in my experience, learners frequently go straight to what they felt they did wrong. 

Context is important as always and Kevin stressed that there is no one best type of feedback process for all learners, at all times, and for all learning outcomes. In addition, for feedback to have an impact learners must be receptive.  Receptivity depends on personal, interpersonal and cultural issues. 

The first part of the Pendleton model relies on the learner’s self-assessment.   Kevin is one of many researchers exploring how well health professionals from student to experienced practitioner are able to assess their own performance.  This self-assessment is considered vital but generally ability has been shown to be poor.

The paradox is that while learners want feedback, they are fearful about receiving it as they are mainly seeking reassurance and not criticism, even if constructive.  Moreover, if the feedback is positive, they may not recognise it as feedback, and if it is negative, it is likely to hurt and affect their sense of professional identity.

We have all been there, both as feedback givers and feedback receivers.  I like receiving compliments but being told I could do better has the potential to make me anxious or resentful, without helping me learn.  Or at least not in that moment. 

Kevin explained that the credibility of the person giving the feedback is important.  He discussed the role of the coach in sport and music performance.  Coaches in these fields tend to stick around with their learners longer than in health professions education where students rotate around placements. A coach needs to be perceived as wanting to help the learner improve and this is more likely if there is a good relationship between the two. 

 Learners need to be put into situations where they can learn, but with support.  Desirable difficulties are situations that enable learners to discover the limits of their knowledge and professional ability, to learn from their mistakes. 

The tension inherent in feedback was summarised as:

• We socialise students and health professionals to view feedback as transformative
• To the point that it is only recognised as meaningful when it threatens the ‘self’
• Which is the very type of feedback that is most likely to be met with resistance. 

I like David Boud’s models of feedback: the concept of feedback as dialogue. 

See the open access Clinical Teacher’s Toolbox here:

https://onlinelibrary.wiley.com/doi/10.1111/tct.12345

To me, a feedback interaction has much in common with patient consultations and requires similar skills: observation, listening, exploring ideas and concerns, and sharing decisions about what should and what could be done after the dialogue. But, as with consultations, we are frequently short of time to do the job as well as we would like without interruption, in a safe space and with undivided attention.  

* Pendleton D, Schofield T, Tate P and Havelock P.  (1984). The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press.