The purpose of giving feedback to learners is to improve their performance. For you, the clinical teacher of medicine, giving effective feedback to your learners is arguably the most important educational action you take. Jack Ende, MD, who writes on giving feedback in medical education, states that "Without feedback, mistakes go uncorrected, good performance is not reinforced, and competence is achieved empirically or not at all."¹ The goal of this column is to help teaching faculty further develop their skills in providing feedback that is timely, effective, and efficient.

To provide timely feedback it can be helpful to remember that feedback you give to learners will at times be formative and at other times summative. Formative feedback is the day to day, encounter by encounter teaching that guides learning through non-evaluative appraisal of the learner's performance to improve their clinical skills. Summative feedback is what occurs at the end of the clerkship when you will give the student a grade. It is an evaluative judgment of their performance. Knowing that we will give summative feedback at the end of the rotation should not make us wait to give our constructive formative feedback in "real time."

There are several important principles to remember when giving formative feedback.¹ One of the most important is creating an educational environment where the teacher and learner are working together as allies, understanding expectations, and sharing goals. Make sure your learner knows that you will be giving them feedback often (including the kind that is built into the directions you will give on how to get the work done) and that its main purpose is to improve their performance. Thus feedback will be expected and ongoing. Optimally, feedback should be given during or right after a learner completes a skill. There may be days when this is more difficult so plan time, even if brief, for feedback at the end of a clinic session or at the end of the day. It is important to remind the learner that feedback will be expected at these times.

Feedback must be based on first-hand direct observations of the learner. The feedback you give should be based on specific behaviors and be constructive, respectful, and honest. Keeping your constructive feedback to one or two important points will help to avoid overload and ensure the advice you give will be followed.

There are two strategies that can be used to ensure that your feedback is educational and effective. We call them "sandwiches" because they each have three steps with the first and third steps being the same like bread around a sandwich. The first strategy incorporates starting with positive feedback, then giving constructive or negative feedback and then remembering to end with giving positive feedback.² We have an important task as teachers to remind our students what they are doing well to reinforce attitudes and behaviors that we want our students to continue. This feedback needs to be specific as well. Telling the learner they "did a good job" but not telling them what they did well is not especially actionable feedback. The second step is the constructive feedback step, and this is where we identify areas for improvement. Every time you give feedback on a performance that needs to be improved you should be teaching how to do it better the next time. This changes the feedback from negative to constructive. The third step is to end with positive comments on their strengths and how the learner will succeed in doing differently next time to improve. Using these steps while giving feedback will also help create an educational environment in which the teacher and learners are working together as allies and develops a climate of trust and comfort for the learner.

The second strategy I would like to describe is important because we want our learners to be active in the feedback dyad. The Positive/Negative/Positive strategy has the student as a relatively passive participant in that we, the teachers, are guessing on what will be helpful feedback for the learner. The second strategy asks the learner what they would like feedback on. The first step in this second strategy, after you have been working with a learner is to ask them to assess their own performance first.³ Asking a question like "What do you think went well, and what could have gone better?" is an example. Not only does the teacher get information about what the learner may need feedback on, but it also helps the teacher to understand the learner's level of insight. The second step is then to tell or teach based on what you have observed. In this step, react to what the learner has observed and give your positive and corrective feedback. The third step is to ask the learner their understanding of your feedback, whether it was constructive, and to develop a plan to monitor the learner's improvement in the future. This strategy helps to individualize the feedback to make it more constructive and engaging to the learner. It also gives the learner a chance to show you how they are improving after receiving the feedback.

Finally, there is some evidence that learners may not always recognize the constructive information you are giving them as feedback.⁴ Consider beginning your feedback sessions by saying something like "I am going to give you some feedback on your performance now," and at the end of the session saying "Was that feedback constructive for you?"

Providing timely, constructive, and explicitly identified feedback within your teaching will help the learner gain the most from each session with you, improve their performance, and ultimately create in them an excellent future physician.

References

1. Ende J. Feedback in clinical medical education. JAMA 1983;250(6):777-81.

2. Davies D, Jacobs A. Sandwiching complex interpersonal feedback. Small Group Behav 1985;16:387-96.

3. Westberg J, Jason H. Collaborative clinical education: the foundation of effective health care. New York: Springer Company, 1993.

4. Bing-You RG, Bertsch T, Thompson JA. Coaching medical students in receiving effective feedback. Teach Learn Med 1998;10(4):228-31.