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- Michael W. Cullen, MD∗ ()
We all know the feeling.
You are finishing a long case in the catheterization laboratory, the eighth case of the day with the same attending. The attending turns as he removes his lead, mumbles something unintelligible out of the side of his mouth, picks his pager from the desk, and turns, walking out of the laboratory and back to his office.
You feel a bit empty. You just labored through 8 grueling cases with 1 of the respected senior faculty in the catheterization laboratory. You thought you made all of the right calls. Access went well, the angiograms you aligned provided high-yield diagnostic information, and you wired all of the lesions for intervention successfully. Ultimately, all of the patients received the appropriate diagnostic and therapeutic care. Upon reflection, you could have done a few things differently. Radial access was a bit tricky on 1 patient. Your communication to 1 of the patients’ families might have been more precise. In a few months, you will finish your training and start on your own. At the end of a day like today, you were hoping for tips to polish your technique and affirmation that you are ready for the next stage. Instead, you must judge your own performance. Could your attending have provided any more effective feedback?
As fellows-in-training and even junior faculty, we all desire feedback. Not just a cursory “strong work” or “job well done,” but specific high-yield information on which we can act and improve. Not only are learners yearning for it, but professional societies and accrediting bodies are now requiring it. According to the Core Cardiovascular Training Statement 4 (COCATS 4), the latest statement of training guidelines published in the Journal, “An optimum training environment includes bidirectional evaluations, in which faculty evaluate and provide positive or negative feedback to trainees and trainees evaluate faculty” (1).
It remains uncertain if fellows and faculty in cardiology training programs are prepared to embrace this proposition. For example, at our institution, a survey of 27 faculty members found that only 15% of faculty indicated that they typically give “mostly specific and behavior-focused feedback.” Findings from a survey of 24 fellows were concordant, with 63% responding that the written evaluations they receive are “mostly adjectives,” whereas only 8% reported receiving “mostly specific and behavior-focused” comments. When faculty members were asked, “How often do you provide face-to-face feedback to fellows on your rotations?” 44% reported “a couple of times throughout the rotation,” and another 32% reported “at the end of the rotation.” However, when asked how frequently they receive face-to-face feedback from faculty, 46% of fellows responded with “rarely, if ever,” and only 4% responded “multiple times throughout the rotation” (Figure 1).
This phenomenon is not specific to cardiology. Multiple specialties in medical education—both procedural and otherwise—have long documented a “feedback gap,” whereby teachers feel that they give feedback but trainees do not feel they receive it (2,3).
As someone who recently transitioned from fellowship to faculty, I am acutely aware of the difficulty in providing feedback. As I begin to practice independently, I am struggling to hone my clinical skills, build my own independent practice patterns, develop an academic niche, and identify an effective teaching style. The issue is doubly complicated when many of my fellows were my former classmates and remain personal friends. For these reasons, maintaining the educational equipoise necessary to provide adequate feedback has been challenging as I start my career as a practicing clinician.
Challenges providing feedback may result from different causes for more senior faculty. Relating to fellows who may be the same age as their children and come from an entirely different technological and educational paradigm could certainly strain the senior educator’s ability to engage and provide feedback to his or her learners.
What can the cardiology community do to overcome this feedback gap, fulfill the vision of COCATS 4, and improve the training environment for our learners, their teachers, and ultimately, our patients? We must find the answers on multiple levels:
1. On an individual level, try to schedule feedback, make it goal-oriented and timely, and focus on behaviors.
a. Feedback takes time. We all know day-to-day patient care can be tremendously busy. Finding extra time for feedback can be a challenge. For example, 74% of faculty surveyed at our institution reported that time constraints were the most significant barrier to the amount of face-to-face feedback they give fellows. Learners and teachers need to decide at the beginning of a workday that they will take 5 to 15 min at the end of the day, regardless of how hectic things are, to deliver feedback. This can be a powerful motivator. It allows learners and teachers to focus on specific learning needs knowing that they have made time to discuss them.
b. Start with the end in mind. As a learner, remind your faculty at the beginning of the day or beginning of the rotation of your goals and objectives for that learning period. Perhaps you are working on intubations for transesophageal echocardiograms. Perhaps you want to have a better understanding of vasopressor management on your cardiac intensive care unit rotation. Perhaps you want to improve communication with referring physicians in your outpatient clinic. If the learners give their teachers concrete, self-directed learning objectives, the teacher can direct feedback accordingly. At the same time, faculty should encourage learners to consider their goals and identify areas where more direct supervision may be necessary to provide more focused feedback.
c. Focus on behaviors. A mentor of mine from residency said, “When giving feedback, tell someone they smell bad; don’t tell them they are ugly.” After a moment of confusion, it made sense. One can fix “smell bad” by taking a nice long shower. One cannot fix “ugly.” In other words, feedback should address individual behaviors, not the individual themselves. By emphasizing behaviors rather than personality, we limit the tendency for feedback sessions to become personal. Thus, feedback can lead to objective actions that facilitate tangible change.
d. Make feedback timely. We can all identify moments from our training when the most effective learning occurred at the point of care. The same can be said for feedback. Feedback is most effective when delivered at the time (or immediately after) the “teachable moment” occurs. For example, after a case in the catheterization laboratory, an attending might say, “Nice job with access on that case. That patient was a ‘tough stick,’ but you palpated, cannulated, and wired the femoral artery without any setbacks or complications.” This feedback addresses the specific actions that the trainee performed well. The same could be said for negative feedback. Regardless of an action’s desirability, delivering feedback immediately after the action occurs reinforces a positive behavior and quickly corrects a mistake.
2. On an institutional level, try to provide confidential mechanisms through which trainees can evaluate faculty and provide academic advancement for renowned educators.
a. Maintain confidentiality. Many trainees express concern that faculty will “hear about” their negative feedback. At the same time, many faculty are acutely aware of their reputation among learners. Although accrediting bodies mandate that learners have access to the identity of their evaluators, institutions carry an obligation to both fellows and their faculty to create systems and cultures that ensure confidentiality of feedback and evaluation data.
b. Reward education. Feedback takes time. Traditional paradigms of academic advancement that reward clinical or research productivity do not reward educational time. Institutions are beginning to recognize the importance of education to the academic mission and reward faculty for their educational accomplishments. Providing effective feedback represents a critical piece of clinical education. As institutions increasingly recognize the academic value of clinical education, effectiveness and specificity of feedback will only increase.
3. As a profession and professional society, try to provide resources to train faculty and fellows how to give feedback and commit to a culture of feedback.
a. Educate the educators. The American College of Cardiology can augment feedback for trainees by offering educational opportunities for academic faculty to improve their feedback skills. These educational opportunities can occur at in-person meetings or through online portals. The College has a responsibility to help its members implement the charges of COCATS 4, and providing members with the skills and knowledge necessary to improve their feedback skills represents a portion of this obligation.
b. Build a culture. As a profession, we have a public obligation to produce the most competent trainees. Building “a culture of feedback” across training programs represents an important component of this mission, because effective feedback can provide the impetus that trainees need to elevate their clinical and professional skills. The improved clinical training, clear identification of one’s learning gaps, and more effective communication of learning goals that stems from this culture of enhanced feedback will only augment the care that cardiologists provide to their patients both during fellowship and after they complete their training.
Feedback plays an important role in cardiovascular education and, ultimately, the quality of clinical care we provide. Unfortunately, feedback during fellowship is frequently deficient. Fellows, faculty, institutions, and professional societies all have an opportunity to improve the feedback that occurs during the “teachable moments” we so frequently encounter.
- Bryan LeBude, MD∗∗ ()
Providing Effective Feedback to Medical Students and Residents
Feedback is a core component of medical education. In his influential paper published more than 30 years ago, Ende (1) defined feedback as an objective, informed, and nonjudgmental assessment of performance targeted at improving clinical skills. The insight gained is valuable in demonstrating the difference between the targeted result and that which was achieved, serving as a driver for change. Providing effective feedback is essential for learner development, because it delineates a continual path for improvement by reinforcing good clinical practices and correcting poor performance.
Despite the recognized importance of feedback, studies surveying trainees consistently show a lack of perceived frequency and quality of feedback from their clinical educators (2). The statement “I never receive any feedback” has stood the test of time as a common complaint among medical students and residents. In the absence of effective feedback, learners are forced to use self-assessment to improve their clinical skills. Unfortunately, inexperienced trainees lack the ability to appropriately identify their own strengths and weaknesses (3). Students and house staff react by developing their own feedback systems, which assign inappropriate value to the internal and external cues experienced (1). For others, lack of feedback may be seen as implicit approval of their clinical skills.
The unfortunate consequence for both trainees and patients is a learner who performs poorly while failing to recognize his or her weaknesses (4). Conversely, the confirmation of competence and skills gained through positive feedback enables learners to build the confidence necessary for independent practice. Trainee self-assessment is not only an ineffective avenue for improving performance, but also reinforces the sensation of being alone in an unfamiliar environment that is commonly experienced by medical students. It is not surprising that the act of receiving high-quality feedback is at the top of traits that students use to define master clinical educators (5).
Simply put, giving useful feedback is a difficult skill to master. Physicians in faculty development courses commonly identify feedback as a skill in need of improvement (6). Many barriers to giving feedback have been described. Most clinical educators have received little or no training in giving effective feedback. Many are discouraged by the fear of causing disappointment or embarrassment in their learners. In the busy environment of academic medicine, educators sometimes have limited opportunities for observing learners in practice due to a myriad of other obligations. Unfortunately, sufficient time is rarely allocated for this activity during the course of the clinical rotation. Time constraints are compounded by the fact that attending physicians may spend only 1 week at a time on the clinical service, limiting continuity with trainees.
As cardiology fellows-in-training, we are uniquely positioned to provide excellent feedback to our medical students and residents. In working closely with our more junior trainees on the front lines, we are often able to observe a wider array of clinical skills than our attending physicians. In addition, fellows are typically scheduled on clinical services for 1-month blocks, thereby providing a much longer period of time to continuously observe the students and residents. Like any of the skills we hope to develop during fellowship training, the art of giving effective feedback requires regular practice that is informed by experts in the field. The following tips can be utilized in building a solid framework for providing trainee feedback:
1. Outline your expectations for the learner at the beginning of the rotation. Students and residents cannot succeed if they do not know which roles they are expected to perform. This becomes a useful reference point when providing feedback at a later date, as it allows learners to easily comprehend the gap between their desired and actual performance. One effective structure for defining expectations and giving feedback, especially for our medical students, is the RIME (Reporter-Interpreter-Manager-Educator) vocabulary (7). This intuitive system defines basic expectations for learners as they progress in their training and helps to specifically identify how they can improve.
2. Prepare the learner to receive feedback. Students and residents often state that they receive little feedback despite surveys of educators reporting regular feedback (8). Eliminate this discrepancy by telling the learner “I would like to give you feedback.” Unanticipated feedback, particularly when it is negative, is likely to be met with an emotional reaction on the part of the learner preventing any comprehension of the teaching points presented. A private setting can also serve to minimize embarrassment or discomfort, in addition to encouraging a dialogue.
3. Ask the learner for a self-assessment. Feedback should be an interactive process that ideally inspires students and house staff to reflect on their performance and plan ways to improve. Begin with open-ended questions like “What do you think went well?” and “What do you need to improve upon?” This makes the discussion of the learner’s weaknesses more comfortable to approach if he or she has already recognized them. In addition, an interactive format provides insight into deficiencies that the student is aware of as well as those the student has not yet identified. Accurate self-assessment is an important skill for lifelong learning that many physicians lack and is one that can only be improved by feedback from an educator (3).
4. A wide array of observed behaviors is worthy inspiration for feedback. Case presentations on teaching rounds need not be the lone source of performance feedback. Various areas can be mined for useful feedback, including: performance of the history and physical examination, clinical knowledge during teaching sessions, progress note content, topical presentations by the trainee, leadership skills in guiding rounds, communication with other health care professionals, and interactions with patients and their families. Regardless of the avenue, powerful feedback is based on firsthand data.
5. Describe to the learner what he or she is doing. Feedback should be based on specific behaviors and decisions. Generalizations regarding performance rarely provide useful information to the trainee. A statement such as “you need to work on expanding your differential diagnosis” provides little insight into how the learner can improve his or her performance in comparison with “an important diagnosis to consider in a patient with jugular venous distention and distant heart sounds is cardiac tamponade.” As a general rule, timely feedback that refers to recently observed behaviors is more likely to be internalized.
6. Focus on the actions observed rather than assumptions of the trainee’s intentions. In addition to creating a more accurate assessment, objective data allows for emotional distance from the feedback for both the educator and the trainee. Feedback language should be neutral, made up of verbs and nouns. This is in contrast to the process of evaluation, which is summative in nature, occurs at the conclusion of a rotation, and renders a judgment on the trainee’s overall performance.
7. Agree on a plan for improvement. For feedback to improve performance, the learner needs to know how to apply this knowledge in practice. Suggest specific ways to bridge the gap between desired and actual performance. The learner should have an opportunity to react to the feedback given and to propose his or her own suggestions for improving performance. The feedback session should conclude with a clearly defined and agreed-upon plan for improvement.
The ability to provide effective feedback is a foundational skill for medical educators. Fellowship represents a valuable time for developing a framework that can be utilized throughout one’s career. By incorporating the tips described in the previous text into a practiced approach, any fellow-in-training should be able to provide his or her students and residents with the feedback they want and deserve.
- Kyle W. Klarich, MD ()
RESPONSE: The Chronic Disease of Medical Education
Several important points about feedback in the learning environment need to be highlighted:
1. Feedback is crucial to the development of learners.
2. Providing feedback in and of itself is a skillset.
3. Feedback can be difficult to deliver.
4. Learning environments are fragmented by short faculty–trainee interactions.
Drs. Cullen and LeBude provide important insights into the significance of, and the all-too-often lack of, feedback in medical education. The perceived absence of feedback needs to improve in the era of competency-based medical education founded on milestones. The philosophy of medical education has evolved with the NAS (Next Accreditation System) (1). Competency-based milestones (2) now serve as building blocks for trainee advancement from a novice in cardiology to “ready for independent practice” and, for some, “aspirational.” Feedback is essential for trainees to gauge their progress, concentrate their efforts, and change their clinical performance (3). Faculty feedback can help to assess the trainee’s readiness to progress. Lack of feedback, whether formative or summative, is the chronic disease of medical education that training directors for generations have tried to cure.
Both Drs. LeBude and Cullen outline pertinent methods that educators can use to master the skill of feedback. It may seem basic. Yet, as Dr. Cullen demonstrates, although most educators feel that they are providing feedback, learners do not perceive that they are receiving feedback. Learners need actionable, behavior-specific comments to advance their performance. Dr. Cullen’s survey of faculty and cardiology fellows demonstrates that a “feedback gap” exists even in an academic center that prides itself on educational tradition. This lack of valuable input both in the formative experiences and in summative assessments leads to the feedback gap. In addition to frameworks highlighted by Drs. LeBude and Cullen, learners share the responsibility in the feedback scheme. They can improve the quality and timing of feedback by actively soliciting it from faculty. This interaction develops a culture of feedback from teacher to trainee and vice versa.
Dr. Cullen highlights the barriers that early career faculty face when giving appropriate feedback. In addition, faculty members must embrace the feedback concept despite a fear of offending the learner. The framework provided can help to alleviate this tension by structuring interactions. The skills of observing and delivering feedback need to be explicitly taught to trainees and reinforced to junior faculty. Evidence suggests that this is not done well in the current training environment (4).
One major challenge to meaningful feedback is time. Faculty members frequently cite time as a reason they do not provide feedback. Furthermore, interactions with trainees are often fragmented. Thus, the trainee receives no, or very limited, formative or summative feedback. Either the environment needs to change (unlikely) or the concept of what constitutes an observation needs to change (possible). Milestones may help to alleviate this tension, as faculty can assess very specific observations—milestones—rather than the whole performance of the trainee. Although prolonged interactions between faculty and trainee, especially in cardiology, are becoming a luxury of the past, evidence suggests that even short encounters can inform the tuned-in evaluator of performance (5). These feedback packets are ultimately stitched together by the trainee to get a complete picture. Great things often come in small packages and may even be more easily processed.
Finally, as an educational community, we need to actively train our fellows and faculty in the methods of feedback and use this as an expected and reinforced performance measure in our academic faculty. This is the only cure for the chronic illness of the feedback gap.
The author would like to thank Drs. Gaby Weissman and Gretchen Diemer for their manuscript critiques and invaluable mentorship.
- American College of Cardiology Foundation