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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.

May 2022: Emotion and Feedback

This month’s article addresses the presence of emotions in the feedback process. The authors assert that investigating emotions in feedback could help address its presence in productive ways.


  • Some feedback models seek to balance positive and negative emotions to prevent defensiveness in the process.
  • Four components of feedback literacy are: appreciating the feedback, making judgments, managing emotions, and taking action.
  • Emotion as physiology: views emotions as biological processes to be managed. This approach treats emotion as damaging to the feedback process.
  • Emotion as skill: views emotions as cognitive and malleable. This approach treats emotion as something that needs to be processed before acting.
  • Emotion as reflexive practice: views emotions as social and interpersonal. This approach treats emotion as an influence on behavior.
  • Emotion as socio-cultural mediator: views emotions as political. This approach treats emotions as mediators in the way a trainee becomes part of a community of practice.

Ajjawi, R, Olson, RE, McNaughton, N. Emotion as reflexive practice: A new discourse for feedback practice and research. Med Educ. 2022; 56(5): 480- 488. doi:10.1111/medu.14700

April 2022: Feedback-Giving Behavior in Clinical Performance Evaluations

This month’s article focuses on feedback behaviors of faculty who use the mini-CEX, or mini-clinical evaluation exercise, to assess student performance and provide feedback.


  • Student performance in the clinical setting is typically assessed following direct observation of a skill or task.
  • Tools such as the mini-CEX allowed supervisors to provide meaningful feedback.
  • Personal educational viewpoints influence the assessment and feedback process.
  • As individuals vary in the ways they collect and process observation data on students, feedback giving behaviors are also variable.
  • Concern with patient safety during consultations results in more frequent observations and higher quality feedback.
  • Written feedback often lacks information students can use to improve their performance.
  • Written feedback is more taxing on supervisors, requiring more time and effort to compile and construct.
  • Long-term supervisor/student relationships improve the quality of feedback in terms of credibility and constructiveness.

Harold G. J. Bok, Debbie A. D. C. Jaarsma, Annemarie Spruijt, Peter Van Beukelen, Cees P. M. Van Der Vleuten & Pim W. Teunissen (2016) Feedback-giving behaviour in performance evaluations during clinical clerkships, Medical Teacher, 38:1, 88-95, DOI: 10.3109/0142159X.2015.1017448

March 2022: Types of Feedback in Medical Education

Feedback drives the learning process towards achieving goals. There are a variety of feedback types in medical education, each serving a specific purpose in helping the teacher and learner work together.


  • Intrinsic, or short, feedback is driven by students.
  • Extrinsic, or long, feedback is driven by teachers.
  • The goal of providing feedback is to help the learner reach their full potential.
  • Competency-based medical education, or CBME, is a student-centered process.
  • Many types of feedback treat the learner as a passive recipient of information.
  • Intrinsic feedback requires a learner to have keen observation skills, self-awareness, self-analysis, and motivation to improve.
  • Extrinsic feedback helps learners calibrate their actual performance to their desired performance.
  • High achieving students rely more on intrinsic than extrinsic feedback.
  • In CBME, the goal of teachers should be to move learners from dependence on extrinsic feedback to use of intrinsic feedback.

Velou MS, Ahila E. Types of feedback in medical education - A new hypothesis in alignment with competency-based medical education. International Archives of Integrated Medicine. 2020;7(8):86-90.

February 2022: Physician Characteristics in Feedback Skills

Feedback is a fundamental component of teaching and learning meant to reinforce strengths and improve performance. Faculty development programs often work to develop feedback skills. This study sought to identify faculty characteristics associated with providing high-quality feedback.


  • Providing high-quality feedback is a complex and fundamental teaching skill set.
  • Learner-centeredness is associated with high-quality feedback. Understanding individual learner needs is an important first step in developing a teaching and learning relationship.
  • Faculty who elicit and process feedback on their own performance were found to provide higher quality feedback to their learners.

Menachery, E.P., Knight, A.M., Kolodner, K. et al. Physician characteristics associated with proficiency in feedback skills. J GEN INTERN MED 21, 440–446 (2006).

Read the full article

January 2022: Outcomes-Based Performance and Feedback

Outcomes-based medical education focuses on development of the competencies expected of healthcare professionals. In her commentary, Sharon Krackov discusses the role of feedback in this process.


  • Deliberate practice is a necessary component of outcomes-based education, with feedback providing essential information for growth and development.
  • Feedback helps a learner achieve and maintain expertise.
  • Feedback in conjunction with formative and summative assessment is the foundation of an iterative curriculum process.
  • Feedback should be a two-way communication tool that engages both learner and teacher.
  • The clinical learning environment may present a barrier to effective two-way feedback.
  • Feedback should be a regular part of the educational experience.

Sharon K. Krackov (2011) Expanding the horizon for feedback, Medical Teacher, 33:11, 873-874, DOI: 10.3109/0142159X.2011.617797

December 2021: Student-Centered Feedback

Feedback is often viewed as a faculty-driven process, with the learner taking a relatively passive role. This month’s article presents a student-centered feedback model that focuses on their requests for and responses to feedback.


  • Faculty-driven feedback may be viewed as something done to students rather than a healthy exchange of information between mature people.
  • Students should take more responsibility for seeking and responding to feedback.
  • Students should actively identify their learning needs and ways to meet them, which may or may not require frequent feedback from a supervisor.
  • Students need to develop a receptiveness to feedback, including placing value on the information they receive as vital to their development.
  • In this model, the quality of feedback is shaped by the student’s ability to seek clarification, evaluate the feedback against their own views, and seeking other opinions that differ or corroborate.

Rudland, J., Wilkinson, T., Wearn, A., Nicol, P., Tunny, T., Owen, C. and O’Keefe, M. (2013), A student-centered feedback model for educators. The Clinical Teacher, 10: 99-102.

Read the full article

November 2021: Giving and Receiving Effective Feedback

Feedback is delivery of data collected from direct observation experiences. Effective provision of feedback takes the giver, receiver, and environment into consideration. Each factor can enhance or hinder the feedback process.


  • All feedback should focus on a specific behavior and include confirmation of understanding and an action plan for improvement.
  • Feedback is formative and should be kept separate from evaluation tasks.
  • Feedback should be a bidirectional conversation between the giver and receiver.
  • Feedback conversations should be labeled as such, priming the giver and receiver to focus on the formative nature of the conversation.
  • There are numerous methods for providing feedback, each with their own advantages and disadvantages.
  • When feedback is predominantly positive, be sure to give the receiver at least one area of improvement to work on so they continue to improve.
  • Receivers should be an active part of the feedback process, routinely soliciting feedback and avoiding defensive behaviors.

Jug R, Jiang X “’Sara”’, Bean SM. Giving and Receiving Effective Feedback: A Review Article and How-To Guide. Archives of Pathology & Laboratory Medicine. 2019;143(2):244-250. doi:10.5858/arpa.2018-0058-RA

October 2021: Relationship, Identity, and Power

Direct workplace observations provide a rich source for feedback in health sciences education. Feedback is influenced by relationships, shaping perception and interactions in ways that can promote and inhibit effective communication. This is especially true when interacting with different health professions, where power differentials may influence provision of and receptivity to performance feedback.


  • Multisource, or 360-degree, feedback is a common tool used in health education to determine competence in the workplace.
  • Data suggests that trainees find feedback more useful when coming from physicians than other health professionals.
  • Health professional feedback to trainees differs depending on the nature of the interpersonal relationship present, such as teacher-learner or peer-peer.
  • Workplace feedback can be both directive and facilitative. Directive feedback seeks to inform the trainee of what needs correction. Facilitative feedback focuses on professional growth and development of core competencies.
  • Role clarity is important in the feedback process, as understanding specific skills and expertise of various team members factors into judging whether feedback is credible.
  • Education programs should implement strategies to help mitigate power imbalances so feedback can achieve desired outcomes.

Miles, A, Ginsburg, S, Sibbald, M, Tavares, W, Watling, C, Stroud, L. Feedback from health professionals in postgraduate medical education: Influence of interprofessional relationship, identity and power. Med Educ. 2021; 55: 518– 529.

Read the full article

August 2021: Feedback and Monitoring Assessment

Feedback is an important component to trainees developing self-regulated learning skills. In competency-based medical education (CBME), trainees are assessed through narrative and numerical ratings obtained from direct observation of skills. CBME relies on the relationships between feedback providers and receivers to foster long-term development.


  • Self-regulated learning involves cycles of establishing learner-endorsed goals, facilitated performance monitoring, and revision of goals based on feedback.
  • The study sought to determine whether narrative and numerical ratings were associated with one another, and whether they were consistent between residents (self) and faculty (observer).
  • Little association was found between narrative comments and numerical ratings from faculty.
  • Reasons for incongruence between narrative and numerical feedback include hedging, where negative feedback is softened, providing exaggerated positive feedback to boost confidence, and focusing on positive feedback to create a safe learning environment.

Egan R, Chaplin T, Szulewski A, et al. A case for feedback and monitoring assessment in competency‐based medical education. Journal of Evaluation in Clinical Practice. 2020;26(4):1105-1113. doi:10.1111/jep.13338

May 2021: Sharing Reflections on Multisource Feedback

Receiving and reflecting on feedback is an important aspect of continuous professional development (CPD). While it is common to review multisource feedback one-on-one with a trusted advisor, new approaches involve reviewing feedback in a peer setting with a trained facilitator. Sharing feedback with others was found to make feedback more meaningful, deepen collegial relationships, and create a sense of urgency for improvement.


  • Multisource feedback does not always result in performance change; multiple studies suggest that facilitation of reflection is required to initiate actual change.
  • Facilitated reflection promotes deeper understanding of feedback and can be accomplished in one-on-one or group settings.
  • Disclosing feedback information in a group setting can be unfamiliar and uncomfortable at first but may develop richer interpersonal relationships over time.
  • Group discussion surrounding feedback may make individuals more open to reflection and subsequent action.
  • Group development of performance improvement goals help to create a sense of urgency to change while allowing participants the opportunity to discuss potential barriers.

Bindels, Elisa, et al. "Sharing Reflections on Multisource Feedback in a Peer Group Setting". Academic Medicine, vol. Publish Ahead of Print, May 4, 2021, doi: 10.1097/ACM.0000000000004142.

April 2021: Learning to Give Feedback

Properly facilitated feedback can improve outcomes and foster analytical learning in trainees. Feedback skills can be learned and are an important part of an educator’s toolkit. This month’s article features two primary methods of providing feedback, Pendleton’s rules and ALOBA.


  • Having been on the receiving end of harsh feedback during training, many instructors are hesitant to provide corrective feedback themselves.
  • Effective feedback involves making trainees aware of their actions and subsequent consequences.
  • Feedback is non-evaluative, objective appraisal of performance.
  • Feedback should be specific, describing behavior that the trainee can change to improve their performance.
  • Having the trainee self-assess can bring up points the instructor wishes to discuss without being threatening to the trainee.
  • Feedback should be based on the trainee’s learning goals, which are established at the start of the teaching/learning relationship and refined over time.
  • With the Pendleton’s rules approach, positives are outlined first to give trainees greater confidence and develop better rapport between the feedback provider and receiver.
  • In the agenda-led, outcome-based analysis, or ALOBA, approach to feedback, the learner identifies the agenda and what they want help with to initiate the discussion.

Learning to give feedback in medical education (PDF)

March 2021: Components of Feedback

A better understanding of how we learn has led to greater appreciation of the importance of feedback in the process. Quality feedback must have a strong basis in observation and evaluation of skills which result in discussion of what is necessary to achieve the next level of performance. While evaluation of skills is at the core of providing feedback, it is the discussion of the evaluation and offering of advice and guidance that turns assessment into feedback.


  • Observation of performance: direct observation of the learner’s knowledge, skills, and attitudes is fundamental to begin the feedback process. Observation should be conducted with a critical eye, a skill that requires continuous attention and development.
  • Evaluation of performance: the learner’s level of performance must be evaluated and used to guide and facilitate development to the next level.
  • Guidance to achieve the next level of performance: the next level of performance should be described to the learner and related to their current performance level. This discussion should include an explanation of the importance and relevance of achieving the next level of performance.
  • Facilitation of performance improvement: facilitating improvement involves the provision of educational resources, learning activities, timelines, and other activities that support the learner in achieving the desired outcomes.

A common problem with feedback is that it often gets skipped in the scheme of educational activities. Feedback also suffers from brevity and lack of details, such as simply stating “good job,” or from being delayed and thus removed from the learning activity and related performance. Providing direct observation with timely and meaningful feedback is thus an important skill to develop as an educator.

Feedback in Medical Education

February 2021: Reflections on Feedback

Learners often report that the feedback they receive is infrequent and/or ineffective. Ramani argues the feedback exchange begins long before the feedback conversation occurs, being initiated upon the learner and instructor first meeting. The establishment of a positive, trusting working relationship is the first step to developing an effective feedback environment.


  • Begin the teaching relationship and feedback process by establishing learning goals. Communicate those goals clearly.
  • Encourage learners to self-reflect as part of the feedback process.
  • Work with your learners to develop improvement plans so they are empowered to act on feedback.
  • Focus the encounter on three questions: Where is the learner? Where does the learner need to be? How do they get there?

Ramani S. Reflections on feedback: Closing the loop. Medical Teacher. 2016;38(2):206-207. doi:10.3109/0142159X.2015.1044950

January 2021: Feedback in Literacy in Learners

Feedback is typically used to improve clinical knowledge and skill development in health sciences students. However, learners often report dissatisfaction with its seemingly one directional, inconsistent, and ad hoc nature. Feedback literacy is one’s ability to recognize, understand, generate, and act on feedback. The concept empowers educators to develop these skills in learners to increase their engagement in the feedback process.


  • Create a safe learning environment in which feedback is an expectation.
  • Foster the learner’s active role in the feedback process.
  • Encourage an appreciation for the intrinsic value of feedback.
  • Facilitate learner’s evaluative judgement development.
  • Manage emotions.
  • Make feedback a focus.
  • Encourage peer feedback.
  • Use exemplars of high-quality work.
  • Use technology to augment the feedback process.
  • Continually evaluate and refine feedback processes.
  • Start early, repeat, and reflect often.

Nicholas Tripodi , Jack Feehan , Rebecca Wospil & Brett Vaughan (2020): Twelve tips for developing feedback literacy in health professions learners, Medical Teacher, DOI: 10.1080/0142159X.2020.1839035

2020 Resources

December 2020: Feedback Resistant Students and Peer Feedback on Teaching Skills
Peer feedback can be a powerful tool. Discussing performance with your colleagues can create a non-threatening environment in which to explore your strengths and weaknesses. These conversations can make us aware of our blind spots, assisting us in improving overall performance.


  • Word choice matters. Choose your words carefully.
  • Allow the individual being observed to determine the goals of the discussion.
  • Maintain confidentiality and focus the conversation on formative feedback. 
  • Focus on skills, not personality. 
  • Use questioning to uncover teaching goals and perspectives.
  • Conclude the process with an action plan.

Lori R. Newman, David H. Roberts & Susan E. Frankl (2019) Twelve tips for providing feedback to peers about their teaching, Medical Teacher, 41:10, 1118-1123, DOI: 10.1080/0142159X.2018.1521953

Feedback in medical education provides important information to foster continual growth. However, the pressures of training and often competitive nature of the environment can shift trainees’ mindset from one of growth to one of outperformance of others. This can lead to feedback resistance in learners, where their ego protects itself against feelings of insecurity and inadequacy.


  • We don’t have a clear understanding as to why some students are receptive to feedback while others are resistant to it.
  • Resistant behaviors include deflection, constructing mental barriers to receiving the feedback, and demonstrating emotional injury when receiving feedback.
  • Increased trepidation with providing feedback may result in a general reluctance to provide feedback at all, which is called vanishing feedback.
  • Medical education is caught in a conflict between the need to continually improve with the expectation of excellence or perfection.
  • Positive feedback may feel better but does little to ensure maturation of the learner.
  • Feedback on the art of medicine is constructive feedback.
  • Feedback on the science of medicine is corrective feedback.

Perrella, A. (2017). Room for improvement: Palliating the ego in feedback-resistant medical students. Medical Teacher, 39(5), 555–557.

November 2020: Classifying Feedback in Competency-Based Medical Education
Feedback is an essential component in the teaching-learning process. Feedback can be classified into two forms: Intrinsic and Extrinsic. Intrinsic feedback is driven by the learner, while Extrinsic feedback is driven by instructors. The authors asset that the goal of the curriculum should be to encourage more Intrinsic feedback.


  • Students must be assessed frequently, and directive information provided to change behaviors as needed.
  • The primary goal of feedback is to aid the learner in achieving their full potential.
  • Feedback should focus on learners’ knowledge, skills, and attitudes.
  • Intrinsic, or short, feedback takes place when only one person (the learner) is involved.
  • Learners engaging in short feedback need self-motivation, self-analysis, and self-directed learning skills.
  • Intrinsic feedback requires that the learner be able to distinguish desired performance from actual performance.
  • Extrinsic, or long, feedback occurs when two or more people are involved in the feedback process.
  • Extrinsic feedback is needed by most students as they are unable to independently discern the difference between desired and actual performance.
  • Competency-based medical education (CBME), which focuses on the learner, we may need to transform the way in which we approach feedback, both intrinsic and extrinsic.

M. Senthil Velou, E. Ahila. Types of feedback in medical education – A new hypothesis in alignment with competency-based medical education. IAIM, 2020; 7(8): 86-90.

October 2020: Individualized Learning Plans for Feedback
Individualized Learning Plans, or ILPs, are supported by self-regulating learning theory, fostering students’ skills in establishing personalized learning goals and plans to achieve them. ILPs encourage reflection, providing a prime opportunity for feedback.


  • Focused feedback is more likely to be provided when a learning goal is presented.
  • Feedback alignment with learning goals does not necessarily improve the quality of the feedback itself.
  • Content, but not quality, of feedback was improved by the presence of a learning goal.
  • Different interventions, such as faculty development, are needed to improve the quality of faculty feedback.

Michelle E. Kiger, Caylin Riley, Adrienne Stolfi, Stephanie Morrison, Ann Burke & Tai Lockspeiser (2020) Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students, Teaching and Learning in Medicine, 32:4, 399-409, DOI: 10.1080/10401334.2020.1713790

September 2020: Feedback Seeking Behaviors of Students
Medical students are increasingly viewed as active seekers of feedback rather than passive recipients of information. Students seek information with two goals in mind: learning and performance. In this month’s article, the authors explored the feedback-seeking behaviors of students in the clinical setting.


  • Motivation, or self-determination, is the mark of an intrinsically motivated individual.
  • High-performing students appear to be more motivated than low-performing students in seeking out feedback.
  • Low-performing students may be more externally motivated than their high-performing peers.
  • Higher self-determination is linked to greater persistence, better self-perception, and better quality of interactions.
  • Higher-performing students appear to seek feedback so they can learn from it, while lower-performing students seek feedback because they are required to do so.
  • Higher-performing students appear to recognize the beneficial nature of formative feedback more than their lower-performing peers.
  • Student awareness of their motivation to seek feedback may increase self-regulated learning, in that learners may be more inclined to seek formative feedback.

de Jong, L. H., Favier, R. P., van der Vleuten, C. P. M., & Bok, H. G. J. (2017). Students’ motivation toward feedback-seeking in the clinical workplace. Medical Teacher, 39(9), 954–958.

May 2020: Challenging Feedback Myths
Feedback is often less effective than we want and need it to be. Viewing feedback as a transaction rather than a process limits its effectiveness and may shift focus away from the most important partner in the process: the learner.


  • Learners need to develop “feedback literacy,” or the ability and disposition to interpret information and translate it into enhancing their performance.
  • Feedback is a process, one that involves bidirectional communication of information that makes a difference in learner’s knowledge, skills, and attitudes.
  • The feedback process is longitudinal in nature, occurring over time and involving the learner seeking information to make judgements about the quality of their own work.
  • Efforts to balance the message through praise-criticism approaches, such as a the “feedback sandwich,” fail to recognize feedback as a process, focusing on feedback as information to be given rather than interpreted and acted upon.
  • Focus on the feedback giving skills of educators fails to recognize the learner’s role in the process and narrows the feedback itself to achievement of competence rather than capability.

Molloy, E., Ajjawi, R., Bearman, M., Noble, C., Rudland, J., and Ryan, A. (2020). Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task. Medical Education, 54, 33-39.

March 2020: Feedback from Medical Students to Faculty
Medical student feedback to faculty is a formalized process in which students anonymously provide unidirectional feedback at the end of a rotation. This feedback is reported to faculty after the rotation ends, ensuring faculty do not alter the student’s performance ratings in an emotional response to the feedback given. While this process serves bureaucratic functions for collecting and recording feedback, and providing data for rank and tenure purposes, it does not foster an environment in which real-time feedback is used to improve instructor performance.


  • Research has demonstrated that feedback is effective when given in a real-time format that fosters interaction between the recipient and the provider. 
  • The hierarchical nature of clinical learning environments may impede the process of learners providing teaching feedback to their instructors. 
  • Faculty report being open to receiving real-time feedback from learners but may be reluctant to accept that dialogue as credible and admit it could bias their grading of students if the feedback received was negative. 
  • Faculty willingness to adapt their teaching based on student feedback may be dependent on who is providing the feedback, what information is provided as feedback, how the message is framed, and why the feedback is being given.
  • Fostering longitudinal relationships and mitigating the influence of summative assessment may improve the development of trusting relationships that encourage bidirectional feedback. 

Robins, L., Smith, S., Kost, A., Combs, H., Kritek, P.A., and Klein, E.J. (2020). Faculty perceptions of formative feedback from medical students. Teaching and Learning in Medicine, 32(2), 168-175.

February 2020: The Art of Clinical Supervision
Clinical supervision is an important part of health sciences training. Feedback is an essential part of clinical supervision, providing trainees with information and insight designed to improve their development. Therefore, developing comfort in providing and receiving feedback is a vital skill for faculty members to develop.


  • Feedback is a two-way, mutually beneficial process. Faculty should expect to give and receive feedback.
  • Feedback enhances the understanding of competence and supports targeted learning. 
  • Feedback is an emotive form of communication, which can lead to discomfort and avoidance out of fear of damaging relationships.
  • In the absence of feedback, students are left confused and unsure about their level of practice.
  • Supervisors often lack confidence in their ability to provide feedback, particularly when there are concerns regarding a trainee’s performance. 


  • Use Bloom’s Taxonomy to plan, deliver, and evaluate learning, which includes provision of feedback.
  • Incorporate both formative and summative feedback into your teaching processes. 
  • Focus feedback on knowledge, skills, and attitudes. 

Russell, K. (2019). The art of clinical supervision: strategies to assist with the delivery of student feedback. Australian Journal of Advanced Nursing, 36(3), 6-13.

January 2020: Broadening the Scope of Feedback
The assumption that providing “good” feedback will result in better learning and performance fails to consider the complexity of learning and behavior change. The historical viewpoint of unidirectional feedback has not yielded the desired outcomes. As such, it may be time to broaden the definition of feedback in the workplace to align it with the complexity of social learning processes.


  • Feedback should be redefined as performance-relevant information, or PRI.
  • “Relevant information” provides a more neutral term, whereas “feedback” denotes a judgement is being made. 
  • PRI appreciates the importance of what the learner considers relevant for their own learning. 
  • PRI focuses on how learners interpret workplace information related to their own learning needs. 
Van der Leeuw, R.M., Teunissen, P.W., and van der Vleuten, C.P.M. (2018). Broadening the scope of feedback to promote its relevance to workplace learning. Academic Medicine, 93, 556-559.
2019 Resources

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.


  • 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.


  • 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.


  • 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.


  • 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.


  • 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.


  • 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.


  • 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

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

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.
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
2018 Resources

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.

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.

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”).

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.

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.

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.

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.

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

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

2017 Resources

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.

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.

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.