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Academic and Student Services

The Feedback Loop

The Feedback Loop is a resource from the Office of Educational Improvement within the Department of Academic Affairs. Each month we identify a resource on the topic of feedback of interest to our teaching faculty.

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November 2019: The Feedback Tango

Feedback is a dynamic partnership, one in which both partners play a role. This relationship proves difficult in medical education, with learners often reporting they do not receive sufficient feedback. An exploration of the content of feedback may shed some light on why the feedback relationship in medical education proves challenging. 

Highlights 

  • Feedback providers are typically reluctant to provide constructive or negative feedback to learners. 
  • Formal feedback tools did not mitigate the tendency to provide predominantly positive feedback.
  • Partners in the feedback relationship need to be open to responding to one another appropriately rather than enter the exchange with a set idea of how they will respond.
  • The feedback partnership should be one of mutual respect, care for one another’s success, and provision of a psychologically safe environment in which the partners feel comfortable discussing shortcomings.
Bing-You, R., Varklis, K., Hayes, V., Trowbridge, R., Kemp, H., and McKelvy, D. (20198, April. The feedback tango: An integrative review and analysis of the content of the teacher-learner feedback exchange. Academic Medicine, 93(4), 657-663.
 
October 2019: Providing Teaching Feedback to Peers

Peers can serve as “critical mirrors” that reflect back to us things we can’t see about ourselves. Such is true in life and in teaching. Peer-to-peer feedback conversations typically focus on a discussion of optimal teaching strategies and an exploration of solutions to difficult challenges rather than a plan for improvement. These conversations are formative and collaborative, not evaluative, in nature. 

Highlights 

  • Let the observed party, or “host,” set the goals for the observation to help them target their own needs. 
  • Establish confidentiality rules. Build a trusting relationship to foster honest and open communication. 
  • Focus on skills, not the person.
  • Be mindful of pronoun usage. Use “You” statements when giving praise and “I” or “We” statements when suggesting changes.
  • Be aware of your own personal biases, such as halo or horn effects. 

Newman, L.R., Roberts, D.H., and Frankl, S. E. (2019). Twelve tips for providing feedback to peers about their teaching. Medical Teacher, 41(10), 1118-1123.

September 2019: Seeking Feedback

The feedback relationship is a complicated one, influenced by numerous factors. When developing a feedback relationship, it is important to remember that feedback is a two-way dialogue and not a one-way transmission of information. Feedback given is not necessarily feedback received, nor does feedback being sought mean the recipient is ready to openly receive and act upon it.

Highlights:

  • Students may confuse formative feedback and summative assessment, distorting their perceptions and reactions to feedback.
  • Students may observe for clues, such as provider mood, before seeking feedback.
  • Faculty need to move beyond simply telling students to ask for feedback and better prepare them to receiving and acting on it. 

Bing-You, R., Hayes, V., Palka, T., Ford, M., and Trowbridge, R. (2018, August). The art (and artifice) of seeking feedback: Clerkship students’ approaches to asking for feedback. Academic Medicine, 93(8), 1218-1226.

August 2019: Establishing a Positive Learning Climate

Establishing a positive learning climate helps teachers and learners overcome the natural tendency toward trepidation regarding feedback.  Prepare a foundation on which learners expect growth-enhancing feedback and feel comfortable accepting constructive criticism of their performance.

Highlights:

  • Set the expectation that you will facilitate frequent, formative feedback conversations.
  • Focus on goals and observed performance when providing feedback.
  • Role model positive behaviors, such as demonstrating respect, a willingness to welcome opinions and a readiness to admit your own limitations and errors.
  • Foster relationships that encourage two-way feedback, allowing the learner to provide formative feedback to you as a teacher. 

Ramani, S., Konings, K.D., Ginsburg, S., Ginsburg, S., and van der Vleuten, C.P.M. (2018, February). Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships. Medical Teacher, 41(6), 625-631.

May 2019: Feedback Redefined

Competency-based medical education relies on formative feedback to provide learners with information essential to their continued growth and development. Unfortunately, trainees often report that meaningful feedback is infrequently provided. Newer models of feedback emphasize the role of the learner in the process, making them an active participant in receiving and acting on feedback throughout the course of their training.

Highlights:

  • The landscape of feedback needs to shift from feedback techniques to the goals, acceptance and assimilation of feedback by learners. 
  • The feedback loop is incomplete until learners act on the feedback they are given.
  • Medical education environments need to promote trusting relationships  between teachers and trainees to enable meaningful exchange feedback.
  • The goal-orientation of learners may have a strong influence on their ability to seek and receive feedback.

Ramani, S., Konings, K.D., Ginsburg, S., and van der Vleuten, C.P.M. (2019, February). Feedback redefined: Principles and practice. J Gen Intern Med, 34(5), 744-9.

April 2019: Feedback Seeking Behaviors of Students

Medical students are motivated by several factors when deciding whether to seek feedback. Bing-You et al. found that students observe their faculty and residents for cues before engaging in a feedback dialogue. To encourage feedback seeking behaviors, faculty should be supportive and constructive when providing feedback. 

Highlights:

  • Feedback is a two-way dialogue and not a one-way transmission of information. 
  • Feedback seekers may tend toward a "learning goal" orientation as opposed to a "performance goal" orientation. That is, their focus may be more on learning than receiving a positive assessment. 
  • Learners' feedback seeking behavior may be influenced by the trainer's leadership style, with supportive leaders inspiring trainees to engage in more feedback in shaping their seeking behaviors. 
  • Learners often weigh the perceived benefits and costs of the feedback in shaping their seeking behaviors.
  • Faculty need to do more than tell students to seek feedback; they need to foster an environment that encourages and nurtures such behaviors. 

Bing-You, R., Hayes, V., Palka, T., Ford, M., and Trowbridge, R. (2018, August). The art (and artifice) of seeking feedback: Clerkship students’ approaches to asking for feedback. Academic Medicine, 93(8), 1218-1226.

March 2019: Meaningful Feedback Conversations

LaDonna and Watling (2018) provide a commentary on their study of feedback in the clinical learning environment. Human motivation is complex, and their findings suggest that formal programs may not overcome lack of internal motivation when it comes to engaging in a meaningful feedback conversation.

Highlights

  • Various forces can discourage learners and faculty from engaging in meaningful feedback conversations.
  • Learners develop their knowledge and skills in a culture permeated with messages about competence and independence, making the vulnerability of honest feedback uncomfortable.
  • Observation and feedback are often viewed as something from which you graduate rather than something that you integrate into practice.
  • Learners may view feedback as a bureaucratic process rather than a learning opportunity.
  • Driving meaningful feedback may require a culture change in medicine that embraces vulnerability.

LaDonna, K.A., and Watling. C. (2018, February). In search of meaningful feedback conversations. Medical Education, 52(3), 250-251.

February 2019: Feedback and Culture Development

Establishing healthy feedback relationships relies on development of a positive feedback culture. Such a culture includes interpersonal relationships and institutional context.

Tips for Developing A Feedback Culture

  • Be a professional role-model and establish a positive learning environment
  • Conduct direct observation to inform your feedback
  • Facilitate reflection and self-assessment in your learners
  • Foster a growth mindset in your learners
  • Encourage feedback seeking behavior
  • Promote learner-initiated action plans
  • Establish an educational alliance
  • Encourage co-creation of learning opportunities
  • Promote balance between supervision and autonomy
  • Establish a continuous practice improvement environment
  • Create a culture that emphasizes personal growth

1. Ramani S, Konings KD, Ginsburg S, van der Vleuten C. (2018). Twelve tips to promote a feedback culture with a growth mind-set: Swining the feedback pendulum from recipes to relationships. Medical Teacher. DOI: 10.1080/0142159X.2018.1432850

January 2019: Feedback and Relationship Development

Teaching and learning is a sociocultural process, one in which relationships between parties play an important role. Feedback relies on development of effective relationships.

Points to Consider

  • Effective feedback interactions require an alliance between the teacher and the learner, with the learner taking an active role in the process.
  • A culture of politeness, while fostering positive relationships, can hinder honesty in the feedback process.
  • Key aspects of a feedback culture include feedback providers, feedback receivers, the feedback relationship, and institutional context.
1. Ramani S, Konings KD, Ginsburg S, van der Vleuten C. (2018). Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships. Medical Teacher. DOI: 10.1080/0142159X.2018.1432850
November 2018: Faculty Behavior: Helping Students Develop an Action Plan

Communicating strengths and weaknesses in a student’s performance is only part of the feedback process. Good feedback includes assisting the learner in identifying next steps and developing an action plan to address areas for improvement.

Tips for Helping Develop an Action Plan

  • Help learners identify new approaches to an identified problem.
  • Provide guidance to learners who understand they need to make a change but don’t know how to do so. For example, when a student understands they need to communicate differently but don’t know what that means from an action standpoint.
  • Help learners overcome barriers to meeting their change goals, such as how to avoid being overwhelmed by their own emotions when using empathy with patients.

1. Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. For assistance in retrieving the full article, please contact MCW Libraries ILLiad system to request a copy.

September 2018: Faculty Behavior: Elicit Learner's Thoughts and Feelings

Feedback should be given when the learner is able to process it. At times, that will mean the feedback giver needs to attend to the thoughts and emotions the learner is experiencing prior to, and even after, the feedback is given.

Tips for Attending to Emotions

  • Conduct a debrief regarding the emotional aspects of an encounter prior to giving feedback. Ask the learner how they felt in the encounter or offer an observation about emotions you witnessed.
  • Role model appropriate emotion handling skills.
  • Give the learner the time and space they need to handle their emotions so they can learn from the feedback when it is given.
  • Check in with the learner after giving feedback to address their emotional state. Use supportive phrasing and questioning to minimize defensive reactions.

1. Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. For assistance in retrieving the full article, please contact MCW Libraries ILLiad system to request a copy.

July 2018: Relate Feedback to Specific Behaviors

Feedback should be a routine activity, woven into the culture of learning. Faculty should strive to provide feedback that is directly related to specific learner behaviors with the goal of helping students self-reflect and modify their performance. 

Tips for Relating Feedback to Behaviors

  • Discuss the learning objectives with the learner before observing their performance. 
  • When observing, take note of behaviors that relate to the learning goals. 
  • Use specific, nonevaluative language to convey observations (e.g., “I noticed you decided to do X” rather than “You should have done Y”).

1. Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. For assistance in retrieving the full article, please contact MCW Libraries ILLiad system to request a copy.  

 
June 2018: Consider the Setting

Faculty should be mindful of the setting when gauging what and how much feedback to provide. Keep in mind the level of privacy provided by a particular setting and the learner’s ability to receive feedback given the day’s workload.

Tips for Selecting the Context of Feedback

  • Provide feedback in a private setting whenever possible.
  • Set aside time for you and the learner to focus on the feedback without extraneous distractions.
  • Focus on one or two skills or behaviors during the feedback session to avoid overwhelming the student’s ability to process the information you provide.

1Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. For assistance in retrieving the full article, please contact MCW Libraries ILLiad system to request a copy.

May 2018: Establishing Goals

Faculty can initiate the process of establishing goals by asking the learner to define what they want to work on given their personal stage of development. Learner-driven goal setting helps the goals to feel more relevant, better engaging the learners in behaviors to meet them. However, faculty should not refrain from suggesting and augmenting goals as they deem appropriate given their observations and expertise.

Tips for Establishing Goals

  • Initiate the goal setting process at the beginning of the teacher-learner interaction.
  • Invite the learner to identify their personal goals (and challenges) to engage them in an interactive process of establishing objectives.
  • Refine goals throughout the teacher-learner relationship, noting learner development and continuing to challenge them to reach the next level.

1Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. For assistance in retrieving the full article, please contact MCW Libraries ILLiad system to request a copy.   

February 2018: Faculty Behavior: Reflecting on Observed Behaviors

One faculty behavior that affects the efficacy of feedback is reflection on observed behaviors1. Reflection allows the teacher to compare the learner’s performance against the learning goal(s) and tailor their feedback to the specific learner’s needs.  Ideally, the reflection process includes faculty and learner reflection to foster collaboration and establish mutual goals.

Tips for Engaging in Reflection

  • During the observation, take note of the learner’s performance as it relates to the learning goals.
  • Ask the learner to reflect on their performance to help you focus what feedback you provide. This can be particularly important when learning goals were not communicated prior to the observation.

1Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239. For assistance in retrieving the full article, please contact MCW Libraries ILLiad system to request a copy.  

January 2018: Improving the Efficacy of Feedback

Research suggests that students value feedback, considering the ability to provide it effectively as an indicator of good teaching1. However, it is important to note that student satisfaction with feedback is not indicative of its effectiveness. Rather, the feedback process should strive to make areas for improvement known in a way that allows the learner to engage in self-reflection and implement changes to their performance. Below are behaviors or skills research specifies may improve the efficacy of feedback.

Faculty behaviors or skills

  • Establish an appropriate interpersonal climate
  • Use an appropriate location
  • Establish goals
  • Elicit learner's thoughts and feelings
  • Reflect on observed behaviors
  • Be non-judgmental
  • Relate feedback to specific behaviors
  • Offer the right amount of feedback
  • Offer suggestions for improvement
  • Handle conflict proficiently
  • Have your own professional goals set in the last year
  • Allow learners to figure things out, even if they struggle

1Thomas, J.D., and Arnold, R,M. (2011). Giving feedback. Journal of Palliative Medicine, 14(2): 233-239.

November 2017: Goal-Oriented Feedback

Feedback is information on performance as it relates to a goal. While it can be, and often is, paired with guidance or advice, feedback itself is devoid of judgment or valuation. Simply put, feedback is a statement of what is or isn't.

Grant Wiggins (educator and author, "Seven Keys to Effective Feedback") tells us, "Information becomes feedback if, and only if, I am trying to cause something and the information tells me whether I am on track or need to change course." Without a goal in mind, attempted feedback is just more information for the learner to try to process.

Key Points

  •  Remind the learner of the goal
    • "Your goal is to obtain a thorough history from the patient. You forgot to ask about social history. What could you have asked to get the information you need?"
  • Be sure the feedback is based on what you observed
    • "Your differential did not include the possibility of disease X."

Wiggins, G. (2012, September). Seven keys to effective feedback. Educational Leadership, 70(1), 10-16. Retrieved from http://www.ascd.org/publications/educational-leadership/sept12/vol70/num01/Seven-Keys-to-Effective-Feedback.aspx

October 2017: When Feedback is Effective

Feedback can be an important educational tool to foster continual reflection and growth. It is dependent on effective instruction, goal setting, and students’ understanding of the assessment process.

Effective feedback relies on communication and interpretation, with the instructor and learner establishing shared goals for achievement and engaging in recurrent communication to foster growth. Learners need guidance on how to revise their current performance to achieve the desired standard. This information reduces the cognitive load so the learner focuses their energy onto the specific aspects of their performance that warrant improvement.

Key Points

  • The success of the feedback process rests in the student’s ability to receive information and interpret it effectively.
  • Feedback needs to engage the learner at, or just above, their current level of performance.
  • Feedback should reassure the student that difficulties in achieving mastery are to be expected, encouraging them to invest the effort necessary to improve.
  • Feedback is enhanced in an environment where errors and discomfort are treated as natural aspects of the learning environment.

1. Hattie, J.A.C., & Yates, G.C.R. (2014). Using feedback to promote learning. In V.A. Benassi, C.E. Overson, & C.M. Hakala (Eds.). Applying science of learning in education: Infusing psychological science into the curriculum. Retrieved from the Society for the Teaching of Psychology website: http://teachpsych.org/ebooks/asle2014/index.php