Linda Johns is an attending physician on a busy inpatient service. She knows that teaching is important, but sometimes she finds it difficult to dedicate the time needed to do it well. That being said, she is proud of the time she does take with the residents, and in particular the time she spends giving feedback to trainees. Recently, she told her resident David, who had been working with her over the last month, “to read more about your patients” and to “work on being more efficient presenting on rounds.” Recently, Linda received a note from the program director that David made a specific complaint: he never received any feedback. What happened here?
What is feedback in learning?
Feedback is a dynamic process intended to confirm positive behaviors and correct negative ones. It is provided by senders (typically teachers) and given to receivers (typically students).(1) In short, it’s about getting input from our mentors and teachers on behaviors that are working well, as well as areas we can work on to improve.
Why do we need to provide feedback to learners?
Feedback is absolutely essential to personal and professional growth, particularly within the field of medicine. To become a better clinician for our patients, effective feedback is required from all sources—educators, colleagues, and yes, even our patients.
Despite being recognized as a fundamental part of the educational process and emphasized for several decades in medical education, feedback is often an area that breaks down under the rigors and pressure of clinical activity. When given effectively, feedback can provide insight into one’s actions, inspire goal setting and help improve clinical performance.(2)
When learners don’t receive effective feedback, they can mistakenly assume they are doing well when they aren’t, or may learn about shortcomings too late to have an opportunity for meaningful improvement. Lack of feedback can foster a learner’s sense of being uncertain or adrift, or that their instructors are not interested in their success.(2)
Barriers to effective feedback include time constraints, working in “public” clinical environments, the fear of being seen as critical on the part of educators, the fear of looking ignorant or becoming defensive on the part of the learners, and most importantly, lacking the skill-set required to effectively give and receive feedback.(2)
How to get better at giving feedback
Delivering feedback skill-sets are not innate, but luckily we can learn, much in the same way we learn to do a procedure or come up with a differential diagnosis. By becoming better at giving and receiving feedback, we can facilitate truly effective learning for ourselves, our colleagues and our patients.
What not to do: In many cases, we give feedback that is not very helpful. Comments like ‘good job’, or ‘work harder on rounds’ do not give a learner anything specific or actionable to work on.
Set up for feedback: Find a location that is relatively private and quiet, and let the learner know that you will be providing formal feedback—a simple sentence like “I’d like to provide you with formal feedback” will suffice.
Give feedback that is: timely, specific, relevant, objective and provides opportunities for improvements.
A helpful method to use is the GO Ask-Tell-Ask method (3):
Before you give feedback
- G oal Setting: Review goals of the educational experience (shared and mutually agreed on)
- O bserve: the skills/behavior on which you would like to give feedback
- Ask: the feedback recipient how they thought the experience went
- Tell: the feedback recipient what you observed (positive elements and areas for improvement)
- Ask: the feedback recipient what they are taking from the conversation and what the next steps might be
Set a plan
Follow up by setting up actionable steps for the learner to follow. Make sure you follow up with the learner as they complete the plan.
How it sounds in practice
Let’s return to Dr. Linda Johns and her interaction with David. She didn’t even realize she wasn’t giving effective feedback until it was brought to her attention. She reviews the GO Ask-Tell-Ask Method.
Set up for feedback: Although she felt like she was giving good feedback, she didn’t set the stage by letting David know she was giving him formal feedback, her feedback wasn’t specific or timely, and she didn’t help come up with a plan to address any shortcomings in a specific and attainable way.
Ask: Linda sits down with David in her office on day three of his month-long rotation and asks David how he thinks the rotation is going. He says he feels like he can ‘get lost in the weeds’ sometimes when giving presentations, and many times he realizes he doesn’t know as much as he’d like about his patient’s conditions.
Tell: Linda notes that she has noticed this as well at times.
Ask: She asks David if he has any thoughts on how to improve in these areas.
The plan: Together they decide that he will read 15 minutes a day on a condition he sees each day, using at least three articles from a primary source each week. At the end of each week, he will spend 15 minutes reviewing ‘top topics’ he had learned about with the team. Additionally, to improve efficiency, they set a goal that each presentation will be 10 minutes or less, with at least three minutes dedicated to discussing the assessment and plan. Finally, they plan to check in again in two weeks to review how things are going, and to adjust the goals at that time if needed.
We have all experienced the frustration of getting bad feedback, and unwittingly, we very likely have been responsible for giving ineffective feedback as well. The GO Ask-Tell-Ask method helps our learners make meaningful improvement, increases the satisfaction in the teacher-learner relationship, and most importantly—ultimately enhances patient care through optimizing medical education interactions.
If you notice a learner who ‘just isn’t getting it’, take a step back and ask if you really have been providing optimal feedback. If not, it’s time to GO Ask-Tell-Ask!
- Ten tips for receiving feedback effectively in clinical practice (Medical Education Online 2014 | 9 minutes) Ali Algiraigri draws from feedback literature and clinical experience to develop 10 tips to empower learners with the necessary skills to seek, receive, and handle feedback effectively, regardless of how it is delivered.
- Giving feedback in the emergency department (UCSF Dept. of Emergency Services | Video, 15 minutes) Developed by emergency medicine physician educators Esther Choo and Michelle Lin.
- “Ask-Tell-Ask” first presented by Konopasek L, Encandela J., Pica G., New York Presbyterian Hospital, Columbia and Cornell Universities, 2006. “GO” added by Moriarty J and Encandela J, at Yale School of Medicine, 2013