Pearls of Effective Feedback

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Giving feedback is hard. It takes time and energy. It can sometimes be uncomfortable. And…we all know of times when we got really useful feedback that helped us be a better doctor, a better teacher, a better person.


The story I often tell is about the intern who gave me truly formative feedback at the end of our rotation together. He started by telling me how great of an attending I was…which is always nice to hear but not really helpful. But then he got more detailed and said he appreciated how supportive I was to incorporating the nurse’s voice and perspective on rounds…except with one nurse. He then described my verbal and non-verbal “tells” that conveyed that I didn’t value her input in the same way. And he was totally right. I was sobered that my feelings about this particular nurse were so transparent. Moreover, that was not the attending I wanted to be. That feedback changed how I behaved on rounds the very next day and is something that I remind myself of on a routine basis. It was incredibly valuable feedback and that intern was particularly brave to give it to me.


So are there things that we can do to facilitate having these sometimes difficult conversations more often and to making them more effective? I hope so. While entire books have been devoted to helping folks develop feedback skills, I’m going to try to distill this down into eight Pearls of Effective Feedback.


1. It’s worth investing the time.

First of all, let’s acknowledge that feedback takes time and we often feel like we don’t have enough of it. However, if we can invest the time upstream, the feedback conversation can be more fruitful. Take the time to observe or gather data. Allocate some time to prioritize topics for your discussion. Protect the time for an uninterrupted discussion. Investing the time increases the odds that the feedback will result in meaningful change.


2. Location matters.

Often “in the moment” feedback is appropriate. But when you need to talk about more challenging topics, it is best to wait to be in a place that is quiet and protected enough that both you and the learner feel like you can speak freely. Sometimes these conversations can become emotional and that is always easier when you are in a safe space.


3. Ask first.

The first step in most effective feedback discussions is to start by asking the learner how they think things are going. This could be a focused question like “How did you think that central line went?” or more general like “How has the first week of the rotation been for you?” The key is that you hear from the learner first. That allows you to see where they are coming from, what insights they do (or don’t) have.


4. Actively listen.

And then you have to really listen to their perspective. There may be more to the story than you know. There may be circumstances that you didn’t understand. Or the learner may already have a great thought on how they could do things better next time. This should be a discussion and part of that means actively listening to your learner.


5. Focus on specific behaviors.

It is a lot easier to change behaviors than personality traits. Part of your job in the feedback relationship is to spend the time identifying specific, modifiable behaviors that a learner can reasonably change. If the concern is that the resident is “dismissive,” what are the behaviors that make people feel that way? This means either directly observing the resident or talking to folks who have worked with the resident and identifying these details.


6. Partner on an action plan.

Of course you will have ideas on how the learner could perform better next time, but change is lot more likely if a learner comes up with the ideas for modifying their behavior on their own. Encourage them to think about next steps and partner with them as you strategize on new approaches.


7. Call it “feedback.”

There is often a disconnect between teachers and learners about whether or not feedback is being given. Not uncommonly, attendings (and others) think that they are giving lots of feedback and trainees do not think they have received any feedback. While there are many reasons for these disparate perceptions, one helpful technique is to always identify feedback as…feedback. Call it out so you are on the same page. This is particularly important for “on the fly” feedback which can be perceived as simple conversation and not formative feedback.


8. Follow up on efforts at change.

Feedback should be a cycle. Observe, identify things to change, try the new approach and re-observe. Did the attempt at change work? Is there progress? Do we need a new strategy? We can’t always close the loop ourselves but in your partnership with the learner, talk about how you can help them continue to work on this change with ongoing feedback.


These eight pearls won’t take away all the challenges of difficult feedback conversations. Hopefully, though, they will make it a little easier for you to partner with your learner and help make a plan for effective change!


Patricia A Kritek, MD, EdM is a Professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Washington. She is a clinician-educator with teaching interests in ventilator management, patient and family centered care, quality improvement in the ICU, feedback, and mentoring.