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LCC:ReceivingFeedback-ResidentA.Moffatt
CanMedsCompetencies: Scholar,Collaborator
What will happen in this session?
In this session, residents should prepare to participate in a discussion with his/her LCC group about giving and receiving feedback. Topics to consider include:
• Barriers to receiving feedback successfully • Strategies that can be employed to use feedback more effectively as both a learner and
supervisor of junior trainees • How to structure your feedback to other learners
Suggested Time 60 minutes.
Pre-session readings: • Algiraigri AH. 2014. Ten tips for receiving feedback effectively in clinical practice.
Med Educ Online. 19: 25141. • Delva D et al. 2013. Encouraging residents to seek feedback. Medical
Teacher. 35(12):e1625-31. • Rider EA. 1995. Feedback in Clinical Medical Education: Guidelines for Learners
on Receiving Feedback. JAMA. 274(12):938i.
Extra Resources: • Giving feedback:
o https://youtu.be/SYXgMobMU8U http://www.practicaldoc.ca/practical-prof/observation-and-feedback/
• One-Minute Preceptor: o https://youtu.be/hmKvei3thwQ o http://www.practicaldoc.ca/practical-prof/teaching-nuts-bolts/one-minute-
preceptor/
2013
2013, e1–e7, Early Online
WEB PAPER
Encouraging residents to seek feedback
DIANNE DELVA1, JOAN SARGEANT2, STEPHEN MILLER2,3, JOANNA HOLLAND4,PEGGY ALEXIADIS BROWN5, CONSTANCE LEBLANC2,4,6, KATHRYN LIGHTFOOT6 & KAREN MANN2
1Department of Family and Community Medicine, University of Toronto, ON, Canada, 2Division of Medical Education,Dalhousie University, Halifax, NS, Canada, 3Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada,4Department of Pediatrics, Dalhousie University, Halifax, NS, Canada, 5Division of Medical Education, Dalhousie MedicineNew Brunswick, Saint John, NB, Canada, 6Continuing Medical Education, Dalhousie University, Halifax, NS, Canada
AbstractAim: To explore resident and faculty perceptions of the feedback process, especially residents’ feedback-seeking activities.
Methods: We conducted focus groups of faculty and residents exploring experiences in giving and receiving feedback, feedback-
seeking, and suggestions to support feedback-seeking. Using qualitative methods and an iterative process, all authors analyzed the
transcribed audiotapes to identify and confirm themes.
Results: Emerging themes fit a framework situating resident feedback-seeking as dependent on four central factors: (1) learning/
workplace culture, (2) relationships, (3) purpose/quality of feedback, (4) emotional responses to feedback. Residents and faculty
agreed on many supports and barriers to feedback-seeking. Strengthening the workplace/learning culture through longitudinal
experiences, use of feedback forms and explicit expectations for residents to seek feedback, coupled with providing a sense of
safety and adequate time for observation and providing feedback were suggested. Tensions between faculty and resident
perceptions regarding feedback-seeking related to fear of being found deficient, the emotional costs related to corrective feedback
and perceptions that completing clinical work is more valued than learning.
Conclusion: Resident feedback-seeking is influenced by multiple factors requiring attention to both faculty and learner roles.
Further study of specific influences and strategies to mitigate the tensions will inform how best to support residents in seeking
feedback.
I do not recall residents really coming forward and
saying, ‘Hey, listen, how was I?’
Background
The majority of learning in postgraduate medical education
occurs through participation in clinical experiences in the
workplace. Residents and their supervisors agree that feed-
back is a crucial component of this process and is essential for
learning (Teunissen et al. 2009; Archer 2010; Watling et al.
2012b) It enables learners to monitor their progress, provides
direction for improvement and informs learners’ self-assess-
ments (Archer 2010). Without feedback, learners may be
unclear as to how well or how poorly they are performing, and
the most expedient actions they should undertake for
improvement (Rees & Shepherd 2005). Self-assessment alone
is unreliable; and feedback from external sources is essential to
confirm or disconfirm self-perceptions (Archer 2010; Sargeant
et al. 2010, 2011). Residents are in the process of developing
self-assessment and self-monitoring skills that will serve them
throughout their professional lives and feedback enables this
process.
Studies consistently show that medical students and
residents feel they do not receive enough effective feedback
while faculty perceive that they provide feedback that may be
under-recognized by learners (Archer 2010; Jensen et al. 2012).
This is an important gap. Moreover, medical education has
generally viewed feedback as information created and
transmitted by a teacher or supervisor to a learner, with the
focus on the supervisor. Hence, research and education
initiatives have addressed strategies for improving the
Practice points
. The feedback exchange model between clinical super-
visors and learners has shifted to include the role of the
learner in seeking and accepting feedback
. The feedback exchange process and resident feedback-
seeking are influenced by multiple factors Both faculty
and learner roles require attention
. Resident feedback-seeking activities appear to be
dependent on four central factors: 1. learning/workplace
culture/climate, 2. relationships, 3. purpose and quality
of feedback, 4. emotional responses to feedback
. Further research is needed to determine how to reduce
the tensions between faculty and learner perceptions of
the feedback exchange process and how to encourage
residents to take an active role in seeking feedback from
their clinical supervisors
Correspondence: Dr. Dianne Delva, Department of Family and Community Medicine, Family Medicine Teaching Unit, North York GeneralHospital, 4001 Leslie Street, Toronto, Ontario, Canada M2J 1E1. Tel: 416 756 6826; fax: 416 756 6979; email: Dianne [email protected]
ISSN 0142–159X print/ISSN 1466–187X online/13/120001–7 ! 2013 Informa UK Ltd. e1DOI: 10.3109/0142159X.2013.806791
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feedback message and the supervisor’s ability to provide
feedback effectively. Less attention has been given to the
learner’s role in seeking feedback.
Recent attention in postgraduate medical education has
shifted to a more learner-focused model with increased
attention to the role of the learner in the feedback exchange
(Hattie & Timperley 2007; Boor et al. 2008; Watling et al. 2008;
Watling & Lingard 2010; Bing-You & Trowbridge 2009;
Goldman 2009; Teunissen et al. 2009, 2007; Krackov 2011;
Milan et al. 2011). An effective feedback exchange requires
learners to be active recipients and seekers of feedback
(Teunissen et al. 2007). Developing a ‘‘culture of feedback’’ in
which learner self-assessment is informed by feedback, feed-
back is embedded in all activities, and trainees feed back to
teachers as well as teachers to students has been promoted
(Cantillon & Sargeant 2008; Archer 2010).
Multiple factors influence whether learners will seek
feedback as needed in clinical settings including external
factors such as supervisors’ receptivity to learners, learner –
supervisor relationships, the learning culture, and internal
factors such as the learner’s confidence and beliefs about one’s
competence (Stewart 2008; Archer 2010; Bindal et al. 2011;
Sargeant et al. 2011). The acceptability and impact of feedback
can be increased if it relates to personally meaningful goals set
by the recipient (Goldman 2009; Archer 2010).
Purpose
In this qualitative study, we explored senior residents’ and
faculty’s perceptions of residents’ feedback-seeking activities,
with the goal of developing strategies to support meaningful
feedback exchange.
Methods
Using an exploratory qualitative approach, we conducted
focus groups with residents and faculty at Dalhousie University
regarding their perceptions of residents’ feedback-seeking
activities. Focus groups enable participants to describe their
perceptions and experiences, hear the reactions and percep-
tions of others, and through discussion explore both shared
and disparate views, potentially adding to understanding
(Liamputtong 2009).
We invited senior residents in specialty programs and
faculty in these programs by e-mail to participate in the study.
Senior residents have more experience with clinical feedback
to draw upon to provide suggestions for supporting feedback-
seeking. To guide the data collection, we developed a semi-
structured interview guide addressing residents’ experiences in
seeking and receiving feedback, and faculty experiences in
providing feedback and encouraging feedback-seeking, bar-
riers or concerns perceived in the feedback exchange from
their respective perspectives, and suggestions for supporting
feedback-seeking. Two trained facilitators conducted the focus
groups. One, KL, was consistent for all groups and the second
was a clinical member of the research team from a specialty
not represented by the focus group participants. This was
undertaken to prevent potential bias by the interviewer.
Focus groups lasted one hour. The facilitators explained the
purpose of the study, obtained consent, and informed
participants that no identifying data would be included in
the transcriptions. In addition to addressing the semi-struc-
tured questions, the facilitators explored related topics as they
arose during the conversation. The focus groups were
audiotaped and transcribed. The study was approved by the
Research Ethics Board of Dalhousie University.
Analysis
We conducted the analysis using an iterative interpretive
process (Miles & Huberman 1994). Team members initially
read the transcripts to develop coding and categories and
identify emerging themes, and then reread and discussed
either the faculty (DD, CL, KM, SM) or resident transcripts (JH,
PAB, KL, JS) in detail to confirm the codes and proposed
themes. Groups met several times for this purpose. Finally, the
groups compared findings across faculty and residents and
developed a concept map (MindManager 2010) to clarify
common themes and differences between the faculty and
resident groups (Figure 1). Differences in interpretation were
resolved through discussion and returning to the data.
Results
We conducted two focus groups each for faculty and residents.
Participants included 10 senior residents (PGY3-5), eight
female, two male; six in Internal Medicine, four in Pathology;
and eight faculty, four female, four male; five in Internal
Medicine, and one each for Surgery, Pathology, and Pediatrics.
Focus group participants confirmed many concerns regard-
ing effective feedback reported in the literature such as the
need for timely, specific feedback that is validated by
observation. Importantly, new findings emerged regarding
feedback-seeking. Themes included four central factors:
culture or workplace/learning climate, relationships between
learners and supervisors, quality of feedback and emotional
responses to feedback. Subthemes were identified and
illustrative quotes including similarities and differences
between faculty and resident perceptions were highlighted
(see Table 1).
Figure 1. Model of interaction of themes influencing
resident feedback-seeking behaviours.
D. Delva et al.
e2
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Tab
le1.
Quote
sillust
ratin
gsi
mila
ritie
san
dd
iffer
ence
sb
etw
een
per
cep
tions
of
facu
lty(F
)an
dre
sid
ents
(R)
with
resp
ect
toIn
fluen
ces
up
on
resi
den
ts’
feed
bac
k-se
ekin
gac
tiviti
es.
Them
e:In
fluen
ces
up
on
resi
den
ts’
feed
bac
k-se
ekin
gS
ub
them
eA
gre
emen
tD
iffer
ence
sin
per
cep
tions
lead
ing
tote
nsi
ons
1.
Cultu
re/c
limat
eR
1:‘‘
Ithin
kth
ere
just
nee
ds
tob
ea
cultu
resh
ift.
Rig
ht?
)...
we
are
ata
teac
hin
gin
stitu
tion.Tea
chin
gsh
ould
be
built
into
the
job
.A
nd
asp
art
ofte
achin
g,yo
unee
dto
let
peo
ple
know
how
they
are
doin
g.’
’
R1:
‘‘If
ind
too
when
you
get
kind
ofuse
dto
not
get
ting
feed
bac
kev
er,yo
ust
op
looki
ng
for
it.’’
F2:’
’It
hin
kth
atif
ther
ew
asa
cultu
reofo
kay,
atth
een
dofth
ed
ayto
day
,Iw
ant
tokn
ow
one
thin
gth
atIca
nim
pro
veon.’
’F1:
‘‘b
ut
the
resi
den
tsin
gen
eral
don’t
seem
togra
spth
efa
ctth
atev
aluat
ion
isve
rym
uch
thei
rre
sponsi
bility
.’’
Saf
ety
R2:‘
‘We
don’t
wan
tto
hav
eourw
ors
tfe
ars
ofi
nad
equac
yre
aliz
edb
yan
ybod
y.’’
R1:‘
‘ther
eis
the
whole
sense
of
safe
tyto
oin
eval
uat
ion,
right?
....if
you’r
eac
tual
lylo
oki
ng
for
info
rmal
feed
bac
kon
how
tob
eb
ette
r,..
....
ther
e’s
still
that
,Ifin
d,
that
des
ireto
conq
uer
that
ITE
Ran
dto
do
wel
l‘‘
F1:’
’or
what
ever
.Id
on’t
know
Don’t
ask,
don’t
tell.
Now
,m
ayb
eso
me
ofth
emfe
el,
‘‘G
eez,
Id
on’t
wan
tto
hea
ran
yb
adnew
s.F2:
‘‘th
ere
are
gro
up
s,in
my
exp
erie
nce
,w
ho
are
anxi
ous
tohav
eve
ryco
nst
ruct
ive
feed
bac
kan
dd
on’t
find
that
thre
aten
ing
...A
nd
oth
ertim
esw
her
eit
would
seem
ther
eis
are
ald
efen
sive
nes
sab
out
any
kind
of
const
ruct
ive
feed
bac
k.’’
Tim
eF
1:‘
‘So
forb
oth
the
lear
ner
who
istr
ying
toget
toth
eircl
inic
,and
forth
ete
acher
who
istr
ying
toget
som
ewher
eel
se,
the
time
pre
ssure
sar
ehuge.
’’R
2:’
’th
ep
erso
nth
atw
asev
aluat
ing
me
had
spen
tve
rylit
tletim
ew
ithm
e.’’
R1:‘
‘they
hav
eth
eir
ow
nth
ings
tod
o,an
dth
eyar
eto
ob
usy
with
thei
row
nst
uff,
or
tryi
ng
tod
ealw
ithth
ere
stof
the
resi
den
ts,
tod
ealw
ithyo
u.’
’F1:
‘‘B
ut
the
resi
den
tnee
ds
tob
ring
that
toyo
ur
atte
ntio
nb
ecau
seif
it’s
ab
usy
clin
ic,
you’r
egoin
gto
forg
et.’
’S
truct
ure
R1:‘‘
I’ve
notic
edth
at,r
esid
ents
on
ase
rvic
ein
thei
row
nsp
ecia
ltyar
em
ore
likel
yto
look
for
feed
bac
kth
anp
eop
lew
ho
are
just
tryi
ng
toget
inan
dget
out.
....
..S
oIth
ink
ther
eis
ad
iffer
ence
bet
wee
nw
het
her
ther
e’s
anow
ner
ship
toyo
ur
ow
nse
rvic
eor
not.
’’F1:‘‘If
ind
with
our
core
pro
gra
mtr
ainee
s,it’
sea
sier
bec
ause
we
hav
em
ore
ofa
longitu
din
alre
latio
nsh
ipw
ithth
em.’
’2.
Rel
atio
nsh
ips
R1:
‘‘Ilik
eth
efe
edb
ack
that
Iget
when
Ife
elit’
sp
erso
nal
ized
and
the
per
son
who
Iw
ork
edw
ithre
ally
und
erst
ood
what
Iw
asd
oin
g,
what
Iw
astr
ying
toac
hie
ve,
and
how
much
time
and
effo
rtIp
ut
into
it.‘‘
R2:
‘‘Lik
eth
eyhones
tlyd
on’t
care
about
the
off-
serv
ice
resi
den
tsth
atar
eju
stth
ere
for
bod
ies.
’’
Com
fort
R1:‘
‘Ifyo
ufe
elre
ally
com
fort
able
with
the
staf
fth
enth
ere’
sno
hes
itancy
.If
it’s
som
ebod
yth
at,
Id
on’t
know
,yo
u’r
em
ore
intim
idat
edb
y,th
ere’
sle
ssof
anin
clin
atio
nto
do
that
.’’
R1:‘‘I’v
enev
ertr
ied
tose
ekoutfe
edb
ack
bec
ause
Ifee
lI’d
be
this
little
pup
py
or
this
little
kid
goin
g,‘‘
Did
Ido
agood
job
?A
reyo
uw
atch
ing
me?
’’..
....
.And
Iju
stfe
ellik
eth
at’s
notth
ety
pe
ofp
erso
nIw
antto
be.
You
wan
tto
port
ray
this
confid
ence
.’’
R1:’
’itse
ems
that
alo
tof
resi
den
tsal
lget
com
fort
able
with
the
sam
eco
up
leof
staf
f.’’
F2:‘
‘So
itw
illb
ein
tere
stin
gfr
om
the
resi
den
t’s
sid
eto
see
how
com
fort
able
they
feel
and
how
app
roac
hab
leth
eyfe
elth
atst
affa
reas
teac
her
sfo
rth
emto
ask
those
kind
of
thin
gs.
’’
R2
‘‘B
ut
inte
rms
of
mee
ting
with
that
per
son
who
mig
ht
be
intim
idat
ing,.
....
.,I’m
not
sure
I’man
yb
ette
rat
it6
year
sla
ter.
’’
3.
Qual
ityof
Fee
db
ack
Conta
ctF1:
‘‘Y
ou
are
work
ing
with
are
sid
ent
ever
ysi
ngle
day
.Then
you
hav
ea
bet
ter
op
port
unity
ofse
eing
how
they
work
and
work
ing
with
them
and
giv
ing
them
som
efe
edb
ack’
’
R2:If
I’ve
gone
and
done
1,0
00
phys
ical
exam
son
pat
ients
,an
dm
yst
affhad
n’t
seen
me
do
one
of
them
,Id
on’t
thin
kth
atth
eir
feed
bac
kis
goin
gto
be
hel
pfu
l.F1:’
’it’
sm
uch
more
diff
icult
when
you’r
eju
std
rop
ped
inso
mew
her
efo
rth
at4
wee
kro
tatio
n..
....
som
ethin
gco
uld
easi
lyget
left
beh
ind
.’’
’’
R2:
‘‘it
has
tohap
pen
around
asp
ecifi
cci
rcum
stan
ce.
Itnee
ds
tob
ed
irect
,tim
ely.
’’R
2:‘
‘Iw
ould
say
that
pro
bab
ly80%
of
the
eval
uat
ions
that
Ihad
inm
yro
tatin
gye
arw
ere
from
staf
fth
atsp
ent
little
time
with
me.
And
it’s
not
use
ful.’
’4.
Em
otio
nal
Res
ponse
:a
bar
rier
R1:
‘‘it’
sp
rob
ably
har
dfo
rhim
tote
llm
e,an
dfo
rm
eto
take
itat
the
time.
Iwas
com
ple
tely
mort
ified
.B
ut
inre
trosp
ect,
Iw
asgla
d.’
’
(contin
ued
)
Encouraging residents to seek feedback
e3
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cMas
ter U
nive
rsity
on
07/1
5/13
For p
erso
nal u
se o
nly.
Learning climate/culture
Participants in both faculty and resident groups agreed that a
culture or learning climate that normalizes and encourages
feedback would open residents to seeking feedback. Faculty
suggested that residents must be expected to take responsibility
for seeking feedback. Meanwhile residents suggested that
infrequent or the lack of useful feedback discouraged feedback
seeking. In addition, the tension between formative feedback
and summative evaluation (such as In-training evaluation
reports, ITERS) was expressed as a barrier to seeking feedback
by residents although faculty did not share the resident concern
that poor formative feedback may affect the final assessment. A
prominent theme for faculty was perceived time pressure.
Residents recognized time as a barrier to approaching busy
faculty but felt that faculty did not spend enough time
observing or working with them to provide meaningful
feedback. Both residents and faculty suggested that ‘‘core
rotation’’ residents, i.e. those working in their specialty program
were more likely to seek feedback than residents on short
placements. Structural changes such as the requirement to have
evaluation forms completed prior to promotion supported
residents in seeking feedback. Another structural trend that
seemed to support regular feedback and feedback seeking was
the ‘‘daily feedback’’ form that was being used in the
emergency department. This strategy was being introduced in
other programs. Faculty members had differing views on the
burden of completing daily forms but agreed that the
information helped them to complete final evaluations.
Relationships
Relationships with supervisors influenced residents’ feedback-
seeking activities. Residents were sensitive to whether super-
visors were interested in helping them learn and dismissed
supervisors whom they perceived only valued them for
providing service. Strongly associated with the relationship
theme was the theme of comfort. Residents were more
comfortable with some faculty members than others, some-
times related to proximity in experience but also to how open
and supportive versus intimidating they perceived the faculty
member. In contrast, faculty were curious about whom the
residents would approach and did not seem to know what
behaviours might encourage feedback-seeking.
Discussions regarding the quality of feedback centered on
the degree of contact. Residents were adamant that lack of
observation diminished the credibility of the feedback
provided, as well as its specificity and usefulness. Faculty
agreed that more time spent with the resident helped them
provide more specific, individualized feedback. Increased
contact allowed faculty to witness residency performance
improvement as a result of the feedback exchange and to
identify learners in difficulty at an earlier stage. Residents
reported that increased contact enhanced their comfort and
willingness to seek feedback.
Emotional response
Both residents and faculty agreed that emotional responses to
feedback were a barrier for residents seeking feedback and for
Tab
le1.
Co
ntinue
d.
Them
e:In
fluen
ces
up
on
resi
den
ts’
feed
bac
k-se
ekin
gS
ub
them
eA
gre
emen
tD
iffer
ence
sin
per
cep
tions
lead
ing
tote
nsi
ons
F2:‘
‘And
soIth
ought,
wow
,sh
eju
stto
tally
took
that
asa
per
sonal
atta
ck.
And
I’msu
rea
lot
of
that
is..
.I’m
sure
alo
tof
itw
asm
ym
ethod
but
also
her
sensi
tivity
.A
nd
soIth
ink
both
of
those
thin
gs
could
be
work
edon."
F2:
‘‘A
nd
it’s
easy
togiv
ep
osi
tive
feed
bac
k.It’
sea
sier
toki
nd
of
let
the
smal
lneg
ativ
eth
ings
go.’
’R
1:‘
‘To
und
erst
and
that
it’s
anat
ura
lfirs
tre
sponse
tofe
elre
ally
def
ensi
ve..
.But
just
toki
nd
of
try
tota
keit
and
pro
cess
itan
dle
tit
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faculty in providing constructive feedback. Residents identified
a number of fears, such as fear of receiving ‘‘bad’’ feedback,
not appearing competent, giving the appearance that they
lacked confidence or the impression they were seeking praise.
Residents in both focus groups suggested that asking for
feedback might ‘‘shine a light’’ on their performance that might
then be found lacking. Hence seeking feedback was often
perceived as a risky undertaking. Faculty were uncomfortable
with providing corrective feedback and the defensive reactions
it might engender.
Discussion
Efforts to support life-long learning require learners to reflect
on their performance and to seek evidence that informs their
self-perceptions and guides learning. Seeking feedback in the
clinical setting from supervisors, colleagues and others can
guide professional development, particularly if areas for
improvement are identified. In this study we explored faculty
and residents’ perceptions of feedback and factors that
influence resident feedback- seeking. Results reveal a
number of influences upon feedback-seeking: the learning
climate/culture (contextual), relationships with supervisors,
quality of feedback, and emotional response to feedback.
Residents provided rich insights into their perspectives and,
while faculty had similar insights, they expressed concerns
about time pressures and beliefs that feedback is a shared
responsibility. Hence, the four influences appear to interact to
support or discourage feedback-seeking (see Figure 1).
Importantly, tensions appeared in response to feedback-
seeking arising from both the residents’ perceptions and those
of faculty. Residents appeared to perceive feedback-seeking as
a risk and mediated this risk by balancing the costs and
benefits of feedback, a finding similar to that of Teunissen et al.
(2009) and VandeWalle et al. (2000). While Teunissen et al.
(2009) also identified the quality of the feedback, relationships
and emotion as moderators, the current study also identified
the learning or workplace climate and culture as a compelling
influence on feedback-seeking. In our qualitative exploration,
residents indicated that the workplace culture/climate strongly
influences their willingness to seek feedback. Residents expect
regular feedback as part of the educational process but were
unlikely to seek it in a setting that seemed to value clinical
work over learning. They expressed frustration that it was
either rare to receive helpful feedback or it was provided only
at summative evaluations when it could not be used to correct
deficiencies. Faculty perceived that the institutional culture did
not support teaching, and time pressures for patient care
interfered with providing feedback. In the complex environ-
ment of clinical teaching, effective structures that support
longitudinal relationships between learners and teachers and
frequent yet efficient and effective feedback such as daily
feedback reports might assist with more effective and balanced
coaching of learners.
Such cultural and structural changes might also assist with
building the relationships for effective feedback. Residents
were more comfortable seeking feedback in their core
program or with more intensive exposure with peers such as
senior residents. Adequate exposure was also important for
supervisors to provide meaningful evaluations and faculty
seemed to feel more responsibility for learners in their own
programs. Faculty expressed frustration with expectations to
evaluate learners on short placements and residents agreed
that evaluations by faculty who had not worked closely with
them were discounted.
Watling and colleagues (2012a) propose that feedback from
supervisors is judged by residents for credibility much more
critically than feedback gained through clinical experience or
from patients. The perceived value of feedback is influenced
by the belief that it is based on accurate observation. Feedback
is enhanced not only by the perception of expertise but also by
the continuity of the relationship (Irby 2007). The residents
were unlikely to seek feedback that they felt was vague, not
based on observation and did not help them to overcome their
deficiencies. They tended to seek out faculty who they felt
took an interest in their learning and gave specific constructive
feedback. Faculty expressed uncertainty regarding their
effectiveness in providing feedback and were frustrated in
not receiving feedback from learners on whether their
feedback was helpful. Learners were wary of providing
feedback to faculty, for fear of repercussions.
The costs or barriers to feedback seeking were strongly
influenced by the emotional aspects of the feedback process.
For some there was discomfort in receiving any assessment,
‘‘good or bad’’. Both faculty and residents referred to the
emotional costs of ‘‘negative’’ or disconfirming feedback. For
residents fear of negative feedback was a barrier to feedback-
seeking, and faculty admitted they often avoided the
discomfort in providing corrective feedback. The residents
recommended that they should be taught to expect the
emotional aspects of feedback and how to self-regulate the
ego costs by both expecting and processing it (Trope & Neter
1994; Nussbaum & Dweck 2008).
Learning about goal orientation may be a useful approach
to assisting residents in developing an approach to seeking
feedback. Goal orientations are described as either ‘‘devel-
oping’’ or ‘‘demonstrating’’ one’s ability. In a learning
orientation, the learner’s goal is to develop competence by
acquiring new skills and mastering new situations, thus being
open to seeking feedback. Alternatively, the goal of perfor-
mance orientation is to demonstrate and validate the adequacy
of one’s competence and thus, the learner is less inclined to
seek feedback unless it confirms the self-perception of
competence (VandeWalle & Cummings 1997; VandeWalle
et al. 2000; Ashford et al. 2003).
In this study we saw evidence of residents with a
performance orientation (‘‘flying under the radar’’) who
seemed inhibited in seeking feedback if their self-perceptions
may be challenged or the final evaluation may be affected.
Alternatively, there was evidence of residents with a learning
orientation who appeared eager for feedback (‘‘either positive
or negative, anything!’’)
Limitations
This study took place in one institution and involved senior
specialty residents which may limit generalizability to other
settings or other training programs. We conducted two focus
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groups each for faculty and residents. We believe we reached
saturation by this method as focus groups allow consensus or
disagreement of topics and subsequent deeper exploration of
themes. Although our study is unique in exploring perspec-
tives from both groups in the feedback exchange process, we
did not bring residents and faculty together to discuss
conflicting perceptions such as the tension between formative
feedback and summative evaluations. We believed residents
were more likely to be open among their peers. A focus group
or educational session that brings residents and faculty
together may be more effective in developing shared under-
standing of the constraints and possible solutions to improving
the feedback exchange. Finally, the interaction of the factors
associated with feedback is likely more complex than we have
indicated in Figure 1. The experience of the feedback
exchange may influence both the relationships and the
perceived quality of the feedback, just as relationships affect
the culture and the culture affects the relationships.
Conclusion
We sought to understand resident and faculty perceptions of
resident feedback-seeking behaviour. We have found that
attention only to the skill of providing feedback is inadequate
to support a culture of feedback in clinical settings. The
workplace/learning culture can be strengthened by structural
changes such as longitudinal experiences, use of feedback
forms and expectations for residents to seek feedback,
coupled with providing a sense of safety and adequate time
for observation and provision of feedback. Attention to the
relationships and emotional response to feedback is necessary
to ensure that both residents and faculty do not avoid
providing meaningful feedback. Each of these elements
interacts to support or discourage residents in seeking feed-
back, an activity which they perceive as being fraught with
risk.
Further study of the cost/benefit of feedback seeking may
result in learning models to facilitate effective feedback
exchange, and cultivate a more effective learning
environment.
Notes on Contributors
DIANNE DELVA, MD, is a Professor of Family Medicine and was an
Associate Dean of Undergraduate Medical Education.
JOAN SARGEANT, PhD, is a professor and acting director of the Division of
Medical Education at Dalhousie University.
STEPHEN MILLER, MD, is an assistant professor of Emergency Medicine,
and the Division of Medical Education Dalhousie University.
JOANNA HOLLAND, MD, is an assistant Professor of Pediatrics at
Dalhousie University.
PEGGY ALEXIADIS BROWN, MA, is a Program Evaluation Specialist for the
Division of Medical Education, Dalhousie Medicine New Brunswick, Saint
John, New Brunswick.
CONSTANCE LEBLANC, MD, MAEd, is an Associate Dean for Continuing
Medical Education and Professor of Emergency Medicine at Dalhousie
University.
KATHRYN LIGHTFOOT, MA, is a Research Associate in Continuing
Medical Education, Dalhousie University.
KAREN MANN, PhD, is a Professor Emeritus, Division of Medical
Education, Dalhousie University.
Acknowledgments
We would like to thank Tanya Matheson for her research
assistance through-out this project. Dr. Holland and Dr. Miller
were the principal investigators on the proposal and all
authors contributed to the conception and design of the study,
acquisition of data, and analysis and interpretation of data. Dr.
Delva drafted the article and all authors participated in the
revisions. Each author is responsible for the entire work.
Ethical approval: The study received approval from the
Research Ethics Board of Dalhousie University.
Declaration of interest: This project was supported by a
grant from the Royal College of Physicians and Surgeons of
Canada/Associated Medical Service (AMS) Inc., CanMEDS
Research Development Grant.
Glossary
Feedback: Specific information about the comparison
between a trainee’s observed performance and a standard,
given with the intent to improve the trainee’s performance.
van de Ridder JM, Stokking KM, McGaghie WC, ten Cate
OT. (2008) What is feedback in clinical education? Medical
Education. 42(2):189–197
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Encouraging residents to seek feedback
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FEATURE ARTICLE
Ten tips for receiving feedback effectively in clinical practice
Ali H. Algiraigri*
Community Health Sciences, University of Calgary, Calgary, AB, Canada
Background: Despite being recognized as a fundamental part of the educational process and emphasized for
several decades in medical education, the influence of the feedback process is still suboptimal. This may not
be surprising, because the focus is primarily centered on only one half of the process � the teachers. The
learners are the targets of the feedback process and improvement needs to be shifted. Learners need to be
empowered with the skills needed to receive and utilize feedback and compensate for less than ideal feedback
delivery due to the busy clinical environment.
Methods: Based on the available feedback literature and clinical experience regarding feedback, the author
developed 10 tips to empower learners with the necessary skills to seek, receive, and handle feedback
effectively, regardless of how it is delivered. Although, most of the tips are directed at the individual clinical
trainee, this model can be utilized by clinical educators involved in learner development and serve as a
framework for educational workshops or curriculum.
Results: Ten practical tips are identified that specifically address the learner’s role in the feedback process.
These tips not only help the learner to ask, receive, and handle the feedback, but will also ease the process for
the teachers. Collectively, these tips help to overcome most, if not all, of the barriers to feedback and bridge
the gaps in busy clinical practices.
Conclusions: Feedback is a crucial element in the educational process and it is shown that we are still behind
in the optimal use of it; thus, learners need to be taught how to better receive and utilize feedback. The focus
in medical education needs to balance the two sides of the feedback process. It is time now to invest on the
learner’s development of skills that can be utilized in a busy day-to-day clinical practice.
Keywords: feedback; self-assessment; self-awareness; career development; medical education
*Correspondence to: Ali H. Algiraigri, 208 � 3111 34 Ave NW, Calgary, AB T2L 0Y2,
Canada, Email: [email protected]
Received: 8 June 2014; Revised: 4 July 2014; Accepted: 9 July 2014; Published: 28 July 2014
Feedback is a dynamic process that involves the
senders (typically the teachers) and the receivers
(typically the students) to confirm positive beha-
viors (by encouraging repetition) and correct negative ones
(by encouraging a change) (1). Despite been recognized
as an integral part of the educational process (2) and
emphasized in medical education for several decades
(3�10), little has been done to empower the receivers
(learners) with the skills to accept and use feedback
effectively (5). This may be a reflection of the hierarchical
medical environment that promotes a one-way flow of
information from teacher to learner. As such, the literature
is rich in describing the mechanism of feedback and how
to deliver it (11). Furthermore, different models have
been published and new ones continue to evolve that cen-
ter on the teacher’s role in providing effective feedback
to enhance medical performance (12). In addition, faculty
development courses and workshops have been implemented
to teach how to deliver effective feedback (13). Despite
all this, the results of feedback are still not optimal and
sometimes even disappointing (3, 14�16).
Self-assessment is the first step in the feedback process
and represents the person’s ability to self-assess for a
particular task. Although, it may sound easy to do, the
literature tells us that we are poor at this skill (17). Indeed,
it is recognized as one of the hardest skills, as described by
Benjamin Franklin in 1750. A recent study explored a few
reasons why we are not good self-assessors; these repre-
sent cognitive (information deficits and memory bias),
sociobiological (unrealistic optimism), and social factors
(inadequate feedback from others) (18). Improving self-
assessment can identify weaknesses and improve accep-
tance of feedback, leading to positive changes in behavior
and performance.
The importance of self-assessment to feedback is be-
coming more crucial with the current shift in the medical
education paradigm toward competency-based curricu-
lums, where learners are expected to achieve specific
Medical Education Online�
Medical Education Online 2014. # 2014 Ali H. Algiraigri. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix,transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
1
Citation: Med Educ Online 2014, 19: 25141 - http://dx.doi.org/10.3402/meo.v19.25141(page number not for citation purpose)
milestones enabling them to practice as competent physi-
cians in their field (19). Effective feedback from both
perspectives, delivering and receiving, helps learners to
achieve those milestones. Simulation-based medical edu-
cation (SBME) gained popularity and has been imple-
mented in most medical schools and feedback is now
considered to be a critical step in SBME (20).
Numerous barriers have been identified that prevent
delivering effective feedback, including medical educa-
tors’ unfamiliarity with the feedback, timing and place
constraints, and concerns with breaking the educational
relationship between teacher and learner with negative
feedback (21). In addition, the educational environment
plays an important role in the process to enhance or limit
the feedback process. On the other hand, there are several
learners’ barriers to seek, receive, and handle feedback
effectively. These include, but not limited to, inaccurate
self-assessment, misconception of feedback as a negative
act, and negative reaction that may prevent a productive
response.
Even if we empower medical educators with the
required skills and enhance the educational environment
about feedback, medical practices are a busy environment
that may limit the feedback process or have an impact on
the way it is given. As such, feedback may be missed or
delivered in a non-optimal way. Generational differences
are also recognized as an important factor in the feed-
back process and may limit its use. All of the barriers
place emphasis on the learner to seek, receive, and then
handle feedback efficiently, regardless of whom, when,
and how it is delivered. Empowering learners with skills
to properly receive feedback will help ensure they gain
the benefits from one of the most important tools in
education (5, 22).
ObjectiveIn this review, 10 key tips are provided to help clinical
trainees seek, receive, and handle feedback effectively.
Table 1 summarizes the proposed 10 tips to improve
receiving feedback.
Tip #1: Self-assessment
As the initial step in the feedback process, self-assessment
is ‘a global judgment of one’s ability in a particular
domain’ (17). Self-assessment is an integral component of
self-regulation and is essential to self-development and
educational growth (17, 23). Unfortunately, the literature
indicates that you are quite poor at doing this (17, 24).
Part of the problem is the way you self-assess by thinking
of the big picture (globally) rather than analyzing each
step separately. Typically, this type of thinking fails to
discover the individual skills of interest. To better assess
yourself, try to assess your performance at certain tasks
by considering the task as a process and break it down
into different components. For instance, when staff ask
‘How things went at a specific patient encounter?’ instead
of looking at the global picture, try to dissect the task into
different steps, such as building rapport with a patient,
history taking, physical examination, and post-encounter
discussion. By doing this, your chance to identify an area
that needs work is quite high, compared to the global
impression.
Tip #2: We all benefit from feedback
Regardless of where we are in our careers, all of us
have blind spots about our abilities that prevent us
from reaching the next stage of growth and development.
Table 2 illustrates the blind spot issue by using the ‘Johari
Window’ (25).
In an ideal situation, a small or negligible ‘blind spot’
quadrant is preferable. One way to achieve this is by re-
ceiving external feedback openly. You will learn things,
either good or bad, about yourself that you were previously
unaware of. By acknowledging that individuals are poor
at self-assessment, and have a blind spot, you can utilize
feedback to help you grow in your career. With that in
mind, feedback will provide you with the opportunity to
learn of your strengths and weaknesses.
Tip #3: Connect well with your instructors
Connecting with your instructors is the bridge that pro-
motes the learning process and initiates dialog about your
performance. Creating a positive and healthy environment
is integral to the feedback process (12). Studies show that
preceptors have a weak relationship with students (26, 27).
Conversely, the discounting of feedback by students is
related to their unfamiliarity with educators (27). Promot-
ing this connection will ease the feedback process and
eliminate a major barrier to a successful and powerful tool
for self-improvement and development.
Tip #4: Ask for feedback
Medical practice is quite busy and feedback being over-
looked or forgotten has been identified in the literature as
one of the barriers to effective feedback (21). Seeking
feedback is a powerful initiative towards making improve-
ments. A proactive approach will encourage feedback and
from the teacher’s perspective, set it as a priority for the
student. The teacher will be stimulated to directly observe
tasks performed by students, leading to opportunities for
productive feedback. Feedback based on observable
behavior is identified as a key element for effective and
respected feedback (3, 5, 28).
Tip #5: Be confident and take positive feedback
wisely
From clinical practice experience, trainees may have
various unproductive reactions to positive feedback ran-
ging from an embarrassing attitude, to fears that some-
thing negative will happen and this is just segue way to
a negative feedback. Remember, your instructor does pay
Ali H. Algiraigri
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Citation: Med Educ Online 2014, 19: 25141 - http://dx.doi.org/10.3402/meo.v19.25141
attention during your clinical practice and observes
positive skills and behaviors that need to be continued
and built upon in your future career. Appear confident to
your instructor by thanking them and be attentive to the
details of positive feedback, because this is the basis for
growth and development. Successful trainees do not stop
when they are good, but instead, take it further and
become even more proficient.
Tip #6: Control your emotions
The feedback process can be emotionally challenging,
particularly when negative or unconstructive feedback is
given. Whenever you are faced with that, try to think
about it as an opportunity for personal growth and
development rather than a failure. You are expected to
make mistakes, regardless of where you are in your career
and sometimes you are not aware of your mistakes. Do
not take feedback personally; the focus is not about you,
but about the action and what needs to be changed. Be
sure to remain calm so you can deal with the feedback.
If you are upset, give yourself an opportunity to calm
down and first think about the feedback objectively
before engaging further.
Tip #7: Take an action plan
Whether feedback is negative or positive, we immediately
try to defend ourselves or rationalize our actions, possibly
preventing understanding of the issue and considering
a solution. Effective listening is a very powerful skill that
allows a clear understanding of the issue and that the
teacher is trying to help. It is essential to clarify any issue
that appears vague and summarize the main concerns to
allow active thinking about an action plan to tackle the
issue. What is important about constructive feedback
is developing an action plan to change and correct the
identified issue (5, 29). Try to develop an action plan that
is SMART (specific, measurable, achievable, relevant, and
time-bound) (30).
Tip #8: Acknowledge the generations
The medical field is populated with different generations,
and every generation is raised with different ideas and
values. Knowing how different generations think and
work will enhance your success with the feedback process
and to understand how different generations think about
feedback. Table 3 illustrates how each generation views
feedback.
Tip #9: Be specific and ask about general feedback
Not every clinician is good at providing feedback. Indeed,
there is insufficient instruction on how to give feedback (21).
Table 1. Summary of the ten tips
# Point of emphasis How to deal with it?
1 Self-assessment Break down the task into different components rather than looking at the global picture.
2 Do I really need feedback? Everyone has a blind spot, which prevents us from reaching the next stage of growth, so go and
discover it.
3 Your preceptor(s) Connect well with your teacher and build up the bridge of success.
4 Little or no feedback Take initiative and ask for the feedback.
5 Positive feedback Thank your instructor and appear confident. Take that task to the proficient level.
6 Your emotion You are expected to make mistakes. It is normal to receive constructive feedback. Feedback is an
opportunity for improvement. Be a good listener.
7 Your turn! What after the
feedback?
Here is what really matters, be part of the constructive action plan and follow that up.
8 Generation differences Acknowledging this will help you to better understand your preceptors.
9 General, non-specific
feedback
Probe and ask questions to figure out what exactly is the point.
10 Be ready for it Situations matter, feedback can happen at any time and in any form.
Table 2. Johari window
Known to self Unknown to self
Known to others Open Blind spot
Unknown to others Hidden Unknown
Table 3. Generation and feedback
Generation Feedback
Traditionalists (1900�1945) ‘No news is good news’.
Baby boomers (1946�1964) ‘Feedback once a year, with lots
of documentation!’
Generation X (1965�1980) ‘Sorry to interrupt, but how am
I doing?’
Generation Y (1981�1999) ‘Feedback whenever I want it at
the push of a button’.
Note: Adapted from Lancaster and Stillman (31).
Ten tips for receiving feedback
Citation: Med Educ Online 2014, 19: 25141 - http://dx.doi.org/10.3402/meo.v19.25141 3(page number not for citation purpose)
A common learner complaint is that feedback is too
general, such as ‘good job’ or ‘your performance wasn’t
great’. Overly general feedback is not helpful (7); however,
this does not mean you should dismiss it. Instead, try
to probe deeper and find out the actual details of the
feedback by asking specific questions as they may lead to
a productive conversation about performance.
Tip #10: Be ready! Feedback is not one type and can
be given at any time
Typically, feedback is viewed as formative assessment,
occurring halfway during a clinical rotation. Feedback
may come at different times and in different formats.
Both short and long formats are used in clinical practice.
Teachers, healthcare workers, and patients also give feed-
back. Situations do matter, feedback is dependent on the
actual situation, and sometimes immediate feedback is
necessary. Even though feedback may take different forms,
it usually targets a common goal by reinforcing positive
behaviors or correcting performance. The focus needs to
be directed to the actual contents of the feedback and not
necessarily the format. Acknowledging this will make
you ready to receive, and subsequently use the feedback
wisely.
ConclusionEven with optimizing the delivery of the feedback,
learner’s self-assessment and receptivity to feedback are
essential to completing the successful feedback process
and thereby change behaviors and practices. The focus
in medical education needs to balance how to deliver
feedback with how to receive it. Faculty development
efforts need to continue and include learner development
efforts. Empowering the learners with skills about how
to seek, receive, and handle feedback, regardless of the
way it is given, will further improve the feedback process
in a busy clinical practice.
The tips provided in this article were intended to
provide learners with a framework of strategies to seek,
receive, and take feedback to the next level of behavioral
and skill changes. The tips are also a useful framework
for teaching learners how to be proactive players in the
feedback process.
Acknowledgements
I would like to thank Dr. Linda Perkowski who I never met in
person but learned a lot from her grand round presentation and
discussion about self-assessment and feedback, which was rich in
valuable points that stimulated me to write this paper.
Conflict of interest and fundingThe author has not received any funding or benefits from
industry or elsewhere to conduct this study.
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Ten tips for receiving feedback
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Resident Physicians Section
Feedback in Clinical MedicalEducation: Guidelines for Learnerson Receiving Feedback
Feedback skills in clinical medical edu¬cation are necessary, valuable, and eas¬
ily taught. Courses designed to helpfaculty and residents become more ef¬fective teachers often include trainingin effective feedback methods. The abil¬ity of residents and medical students toreceive feedback as active participantsin the learning process is essential foreffective learning.
Feedback must be received in a waythat serves to improve learning and per¬formance. Because skills in receivingfeedback have not been emphasized, we
developed the following guidelines.1. Remember that receiving feedback
effectively requires a degree of matu¬rity, self-awareness, and a commitmentto the goals of learning clinical skills andimproving clinical performance.
2. Formulate learning goals for your¬self and share these with your supervi¬sor. Learning goals should be mutuallyagreed on at the beginning of a clinicalrotation or learning experience. Feed¬back can then be linked to your learninggoals.
3. Take an active rather than passiverole in receiving feedback. Seek feed¬back as an ongoing part of your clinicallearning, both on a day-to-day basis andin formal feedback sessions.
4. When receiving feedback, ask forspecific examples if your evaluatorgives none. Seek clarification whereverneeded. Additional information can behelpful whether the feedback is positiveor negative.
5. Ifyou are given negative feedback,make sure you understand what the is¬sue is, why it is an issue, and what canbe done about it. Ask as many questionsas needed to gain clarification. Be in¬volved in formulating solutions to im-
prove the situation. Where appropriate,develop a concrete plan for implement¬ing improvements. Because negativefeedback can be (though rarely is) a prod¬uct of interpersonal conflict between youand your evaluator, ifyou feel this mightbe the case, use a trusted adviser orfriend to help sort out the issues.
6. Consider the feedback you receiveas an opportunity for growth and learn¬ing. Use your adviser, mentors, andfriends as sources for gaining an en¬
larged perspective.7. When receiving feedback, discuss
not only what you can do to improve,but also what you are doing well, yourstrengths, and your progress. If learn¬ers are unaware of things they are doingwell, they may drop some of the positivebehaviors from their repertoires.
8. Accept positive feedback as an op¬portunity to gain a clearer sense ofyourstrengths and to provide an impetus forfurther growth.
9. Do not be too hard on yourself; youmay be your harshest critic. Give your¬self credit for what you do know andwhat you do well.
10. Timingis important. Ifa feedbacksession is offered when you are stressedor rushed, ask to reschedule.
Feedback is an important teachingmethod that plays an essential role inthe clinical teaching process and in op¬timizing patient care. Skills in givingand receiving feedback can be learnedand refined; developing an open and in¬quiring attitude toward feedback recep¬tion can facilitate learners becoming ac¬tive participants in the learning process.
Elizabeth A. Rider, MSW, MDChildren's HospitalHarvard Medical SchoolBoston, MassH. Esterbrook Longmaid III, MDNew England Deaconess HospitalHarvard Medical SchoolBoston, Mass
Edited by Charlene Breedlove, Associate Editor.
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