Words Hard to Say and Hard to Hear

Nothing pleases clinical teachers more than to observe the progress of their learners. Yet much must transpire for this to occur. Essential to this process is the provision of feedback to learners to guide them toward performance goals. Providing feedback is easier said than done. There can be a certain discomfort in giving or receiving feedback. It is a vulnerable interaction that exposes instructors' assessment skills and students' performances. Such direct communication can threaten perceived popularity or conjure up previous negative experiences involving feedback. Sometimes, it is easier to ignore feedback altogether. Indeed, students chide their medical teachers for faltering in this area.^{1, 2}

Fortunately, when clinical teachers are given tools to provide feedback effectively, they can overcome these problems and communicate their assessments to students. Programs to improve attending physicians' feedback skills, along with other teaching behaviors, emerged in the early 1980s and rapidly proliferated. Their initial success sparked efforts to augment the feedback behaviors of resident teachers ³ and those who supervise in the outpatient setting.⁴ Local programs are now commonplace. If they are unavailable, regional and national programs exist.⁵

Through the years the techniques for giving effective feedback have been undisputed, although unconfirmed. Authors have advised clinical teachers to create an unthreatening learning climate and to provide learners with feedback that is relevant, understandable, descriptive, verifiable, comparative, specific, focused on behaviors, nonjudgmental, ongoing, timely, limited but sufficient, reciprocal, unfinalized, and impactive with an action plan for improvement.^{1–4, 6} This long list can bog down even the best teachers. A more facile, verified approach is needed.

In this issue, Hewson and Little whittle down the list of important feedback techniques to nine by using an innovative approach to substantiate feedback behaviors.⁷ They asked participants who received feedback during a medical interview course first to describe whether receiving feedback was helpful to them, and second, to rate the individual feedback behaviors they received during each feedback event using a semantic differential scale ⁷ and narrative responses. Participants recalled a greater number of feedback events that were helpful than were not helpful. Nine commonly recommended feedback behaviors were associated with feedback sessions that helped the learner, and six nonrecommended behaviors were associated with feedback sessions that did not help the learner. Learners welcomed correction when evaluators used the recommended feedback techniques, and they appreciated reinforcement, particularly when evaluators offered praise in sufficient detail. The narrative replies corroborated the findings on the rating scales, thus strengthening the authors' conclusion that these data verify nine recommended feedback techniques.

Limitations of this study must be considered. The clinician educators and behavior scientists invited to the communication course may represent a select population of enthusiastic and talented feedback givers and feedback receivers who anticipated analyzing and being analyzed during the course. This energetic group of educators may have had an advanced ability to recognize feedback behaviors (and thus may have overestimated the association between specific behaviors and helpful feedback events) as well as great appreciation for any feedback that they received (and thus may have underestimated the number of unhelpful feedback events). Conclusions drawn from these one-time, simulated interactions may not apply to the ongoing relationships established on the wards and in the clinics between clinical teachers and learners. Finally, the use of the semantic differential survey is relatively new in this context. There are no a priori ratings to help the reader understand the clinical importance of the scores found in this study. Therefore, it may be more correct to conclude that this study shows how these nine feedback techniques rank in importance with respect to one another. In all likelihood, further work using the semantic differential survey will substantiate these recommended behaviors, because the behaviors have such an acceptable and time-tested face value.

Understanding that keeping up with nine feedback behaviors is a bit ponderous for any clinical teacher, Hewson and Little offer some assistance. They organized the feedback behaviors in their study into a larger framework for feedback outlined in their Table 2.⁷ Future studies using such methods as factor analysis will determine if the individual feedback techniques apply to the theoretical constructs of their model. But for now, educators will find this framework useful for augmenting their understanding and recall of this important teaching skill. Stated simply, teachers are to encourage learners to participate in an effort to move them toward mutually acceptable goals (climate). Along the way, teachers should determine the learners' level of understanding about their progress toward the educational goals (elicitation), then teachers are to detail their assessments of the learners' progress, while balancing the number of corrective and reinforcing comments and avoiding statements that are not based on verified behaviors (diagnosis and feedback). Finally, teachers and learners should work together to establish a plan of action to help the learners to improve, and before adjourning, they should agree on the fairness of the feedback discussed (application and review).

Providing feedback is a small price to pay to help learners advance. The benefits will be realized when teachers agree about the importance of feedback and learn a few tips on how to provide it. Feedback is an ongoing process, but not all of the available techniques can be used at all times. Clinical instructors can learn to discern the teachable moments and tailor their feedback accordingly. For example, a focused discussion on a student's bedside presentation may be appropriate on the way to get coffee after the first day of rounds (this author calls this “feedback on the fly”), while a more extensive interchange about other behaviors of the student may occur in private halfway through the rotation. What student would not welcome such input? Watching the student grow, what teacher would hesitate to provide it? Whether received or given, feedback is a gift that is not to be ignored, but revered and pursued.—Anderson Spickard III, MD, MS, Vanderbilt University School of Medicine, Nashville, Tenn.