By: Teri L. Turner
I’ve been reflecting on the concept of feedback and why we, as teachers, can’t seem to get it right. When I ask clinician-educators to reflect on what skills they would like to improve, feedback is invariably the top answer from everyone. When I review learner surveys, the lowest scoring item is always ‘satisfied with faculty feedback.’ I too do not feel that I’m an expert in giving feedback and I continue to attend workshops and read voraciously on the topic. I’ve learned about countless models for giving feedback and there are over 1300 MedEdPORTAL publications devoted to this topic. The number of articles published on learner feedback has grown exponentially over the past 20 years. By this time, with all these resources and all this training, shouldn’t we be better at feedback? Or do we have the concept of feedback all wrong. In the book ‘Think Again: The Power of Knowing What You Don’t Know,’ Adam Grant dares the reader to reconsider what we know, challenge assumptions, seek out information that goes against your views and invite others to question your thinking.1 Is our view of feedback flawed? What if how we deliver feedback does not actually improve outcomes? Or even worse, what if how we are delivering feedback is more harmful than helpful?
For feedback to have any chance of being internalized by the learner, we, as teachers, have to start from a lens of engagement with a grace-filled mindset. I feel confident that trainees do not come to work and say: I’m going to see how much I can do it wrong today just to watch Dr. Turner get upset.” A basic assumption we should adopt is everyone is here because they are intelligent, caring, well-trained and motivated adults who want to learn and become even better. Brené Brown has created a reflective tool to determine whether or not an educator is ready to engage in this type of feedback.2 I try to pull this checklist out before I begin any difficult feedback conversation. The first three reflective statements are:
- “I’m ready to sit next to you and not across from you.”
- “I’m willing to put the problem in front of us rather than between us (or sliding it toward you).”
- “I’m ready to listen, ask questions, and accept that I may not fully understand the issue.”
This last statement is particularly apropos for giving feedback. We must seek first to understand. We often come to the feedback table with bias, judgments and the false assumption that we know exactly what is going on and why. In the simulation world, there is a wonderful technique called advocacy inquiry and it is grounded in debriefing with good judgment.3 It is based on the principle that neither, either, or both of us (feedback giver and receiver) have the ‘truth.’ It is listening to understand, suspending judgment, reflecting on personal biases, and being curious. \”I see what you are doing and given my view, I don\’t get it…\” Instead of making judgements based on assumptions, we should be better at describing what we see. I thought I was good at observation, until I went through a session given by the author of the book ‘Visual Intelligence.’4 Amy Herman uses art to practice describing what you see in order to minimize assumptions and inferences. You can even try your skills at differentiating between subjective and objective conclusions at: https://www.visualintelligencebook.com/blog/conclusions/
I haven’t had a lot of success as a physician, teacher, wife, mother or friend in telling people what they are doing wrong and having them turn to me and say – “WOW – I’m so glad you told me that, I’m going to change what I’m doing from now on.” The concept of me TELLING someone they need to change doesn’t cause change. If pointing out errors was the panacea, then all my patients would have developed healthier lifestyles, all my trainees would read more on their patients and my husband and sons would put the toilet seat down. Just telling someone they are doing something wrong doesn’t cause the person to change. In fact, focusing people on their shortcomings actually impairs learning. Our goal should be to build trust and a safe environment for a trainee to reflect on their performance and establish their own action plan. An evidence-based, theory informed model to facilitate feedback and practice improvement grounded in humanism and learner-centeredness has been published called R2C2.5,6 It is a 4-phase model which facilitates learner self-assessment grounded in the principles of humanism. The four phases are:
- Building relationships and rapport,
- Exploring reactions to feedback,
- Exploring feedback content and
- Coaching for change.
When I’m teaching on this model, I’m invariably asked the question, but what if the trainee isn’t ready to change? In clinical practice, I use the Transtheoretical (stages of change) model to assist me in determining where a patient is along the continuum of change. Milan et al. share how they have applied this same framework to learners.7 For those learners who may be in the precontemplative stage, motivational interviewing can be a helpful adjunct. Developing discrepancy, avoiding argumentation and rolling with resistance can be hard for training program leaders as we tend to want to take control and tell the learner what to do and how to do it. John Whitmore has stated “Coaching is unlocking a person’s potential to maximize their own growth.“ In motivational interviewing the teacher serves as a guide and allows the learner to drive the process. If you have ever taught your own child to drive, the process can engender the same feelings of loss of control. However, true learning and growth will only occur at the learner’s pace. With guidance and a lot of patience, in the end you will have an empowered and motivated trainee.
In the Epilogue of the book ‘Think Again’ there is a quote from Emma Goldman that reads: “What I believe is a process rather than a finality.” Just as Competency Based Medical Education has been a radical change from how we have delivered education in the past, perhaps the time is now to radically rethink feedback. Because if we keep doing things the same old way, you’ll find yourself like me, disappointed and frustrated, stuck in the toilet because someone didn’t put the seat down again.
Below you will find some of my own motivational interviewing scripts that I use with trainees.
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About the author: Teri L. Turner, MD, MPH, MEd is a tenured Professor of Pediatrics at Baylor College of Medicine, where she serves as the Assistant Dean of Graduate Medical Education and the Vice Chair of Educational Affairs. She is the Founder and immediate past Director of the Center for Research, Innovation, and Scholarship in Medical Education for the Department of Pediatrics.
Resources, references and tools (If an item is starred* it is a recommended book for your Summer Reading List!)
1.Grant, A., 2021. Think Again: The Power of Knowing What You Don\’t Know. 1st ed. New York, New York: Viking.*
2. Brown, B. 2022. Dare to Lead. The Engaged Feedback Checklist. Retrieved from: https://brenebrown.com/resources/the-engaged-feedback-checklist-dc/ Accessed July 5, 2022.
3. Rudolph JW, R Simon, RL Dufresne and DB Raemer. There\’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simulation in healthcare. 2006;1(1), 49-55.
4.Herman, A. Visual Intelligence: Sharpen Your Perception, Change Your Life. 2016. Boston, MA: Mariner Books.*
5. Sargeant J, J Lockyer, K Mann, E Holmboe, I Silver, H Armson, E Driessen, T MacLeod, W Yen, K Ross, and M Power. Facilitated reflective performance feedback: developing an evidence-and theory-based model that builds relationship, explores reactions and content, and coaches for performance change (R2C2). Academic Medicine. 2015; 90(12), 1698-1706.
6. Sargeant J, H Armson, E Driessen, E Holmboe, K Könings, J Lockyer, L Lynn, K Mann, K Ross, I Silver and S Soklaridis. Evidence-informed facilitated feedback: the R2C2 feedback model. MedEdPORTAL. 2016; 12, 10387.
7. Milan FB, SJ Parish and MJ Reichgott. A model for educational feedback based on clinical communication skills strategies: beyond the\” feedback sandwich\”. Teaching and learning in medicine. 2006;18(1), 42-47.
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