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Medical Teacher Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/imte20
Reflections on feedback: Closing the loop a
Subha Ramani a
Brigham and Women's Hospital and Harvard Medical School, USA Published online: 08 Jun 2015.
To cite this article: Subha Ramani (2015): Reflections on feedback: Closing the loop, Medical Teacher To link to this article: http://dx.doi.org/10.3109/0142159X.2015.1044950
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
2015, 1–2, Early Online
PERSONAL VIEW
Reflections on feedback: Closing the loop SUBHA RAMANI
Downloaded by [] at 04:55 10 July 2015
Brigham and Women’s Hospital and Harvard Medical School, USA
Lately, I have been reflecting a lot about feedback in medical education. One might think this is old hat with no new avenues for exploration, but that would be far from the truth. The feedback literature is dominated by the benefits and mechanics of feedback, yet our trainees continue to lament on the deficiencies of feedback received by them. Medical students and residents report that feedback given by their teachers is both infrequent and/or ineffective (Bing-You & Trowbridge 2009; Delva et al. 2013). Why does this trend continue when so much has been written about techniques for giving feedback and more faculty development workshops are being organized on this very topic (van de Ridder et al. 2008; Krackov 2011; Krackov & Pohl 2011). My focus has turned to exploring the feedback loop; not the one where teachers give feedback, learners listen and mostly reject the feedback, they all go home and none’s the wiser. The loop starts well before the feedback conversation is planned. It begins when the teacher and learner meet for the first time, regardless of the duration of the teaching experience.
The importance of the learning environment A positive learning environment is established at that introduction where the stage is set for future feedback exchange. A congenial environment is conducive to learning, making mistakes and learning from them, honest admission of limitations on both sides and a willingness to learn from all levels; it also establishes trust between teachers and learners. The trust ensures that feedback is a two-way exchange, includes discussion of strengths and weaknesses, always with professional growth and improvement as the goal of the exchange (Krackov & Pohl 2011; Lombarts et al. 2014).
This quote is very apt when we consider how feedback is provided to learners in medical education. Once a positive learning climate is established, the obvious next step would be communication of learning goals (Chang et al. 2011). Educational leaders need to communicate goals and objectives of the rotation or course to those who teach, teachers should communicate these goals as specific behaviours to learners and learners should establish their own learning goals and communicate these to their teachers. Together, teachers and learners can calibrate their performance at various stages to determine goals achieved and those yet to be achieved.
The importance of reflection Asking students to think about their work before receiving feedback scratches up the soil in their brain so the feedback seeds have a place to settle in and grow – Jan Chappuis Encouraging self-reflection on strengths and weaknesses is an essential factor in training reflective practitioners (Cantillon & Sargeant 2008; van Hell et al. 2009; Krackov & Pohl 2011; Chappuis 2014). I like the Pendleton approach which places self-assessment at the centre of a feedback exchange (Pendleton 1984). I have found that medical trainees are overachievers and tend to be their own worst critics; frequently I end up refuting their gloomy selfappraisals expanding on and highlighting the positives. Thus, starting a conversation with self-reflection can potentially minimise anger, negative emotions and lack of receptivity to corrective feedback (Sargeant et al. 2008; van Hell et al. 2009; Delva et al. 2013). Of course, there are always exceptions to this general principle and teachers must be prepared for those.
The importance of plans The importance of learning goals Everyone is a genius. But if you judge a fish on its ability to climb a tree, it will live its whole life believing it is stupid – Albert Einstein.
Feedback serves no purpose if recipients do not list their specific strengths and areas that need improvement in terms of learning outcomes and describe professional improvement plans (Boud & Molloy 2013; Watling 2014a, b). To achieve this, feedback is best based on specific behaviours, close
Correspondence: Subha Ramani MBBS, MMEd, MPH, Assistant Professor of Medicine, Harvard Medical School, Internal Medicine Residency Program, Brigham and Women’s Hospital, 75 Francis Street, ASB 1&2, Boston, MA 02115, USA. Tel: (617) 732-6040; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/0000001–2 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1044950
1
S. Ramani
observation and aimed at motivating professional development. This completes the feedback loop. I think it’s very important to have a feedback loop, where you’re constantly thinking about what you’ve done and how you could be doing it better. I think that’s the single best piece of advice: constantly think about how you could be doing things better and questioning yourself – Elon Musk
Downloaded by [] at 04:55 10 July 2015
And finally . . . Perhaps I could conclude by simplifying the purpose and process of feedback. Those receiving feedback, teachers or learners, should be able to answer the following three questions at the end of a feedback conversation: (1) Where am I? – Calibration of performance, strengths and areas for improvement (2) Where do I need to be? – Outcomes to be achievedknowledge, skills and attitudes (3) How do I get there? – Reflection, self-assessment and action plan
Notes on contributor SUBHA RAMANI, MBBS, MMEd, MPH, is the Director of Evaluation for the Internal Medicine Residency Program at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School.
Declaration of interest: The author reports no declarations of interest.
2
References Bing-You RG, Trowbridge RL. 2009. Why medical educators may be failing at feedback. JAMA 302:1330–1331. Boud D, Molloy E. 2013. Feedback in higher and professional education: understanding it and doing it well. London, UK: Routledge. Cantillon P, Sargeant J. 2008. Giving feedback in clinical settings. BMJ 337: a1961. Chang A, Chou CL, Teherani A, Hauer KE. 2011. Clinical skills-related learning goals of senior medical students after performance feedback. Med Educ 45:878–885. Chappuis J. 2014. Seven strategies of assessment for learning. Upper Saddle River, NJ: Pearson Education. Delva D, Sargeant J, Miller S, Holland J, Alexiadis Brown P, Leblanc C, Lightfoot K, Mann K. 2013. Encouraging residents to seek feedback. Med Teach 35:e1625–1631. Krackov SK. 2011. Expanding the horizon for feedback. Med Teach 33: 873–874. Krackov SK, Pohl H. 2011. Building expertise using the deliberate practice curriculum-planning model. Med Teach 33:570–575. Lombarts KM, Heineman MJ, Scherpbier AJ, Arah OA. 2014. Effect of the learning climate of residency programs on faculty’s teaching performance as evaluated by residents. PLoS One 9:e86512. Pendleton D. 1984. The consultation: An approach to learning and teaching. Oxford, UK: Oxford University Press. Sargeant J, Mann K, Sinclair D, van der Vleuten C, Metsemakers J. 2008. Understanding the influence of emotions and reflection upon multisource feedback acceptance and use. Adv Health Sci Educ Theory Pract 13:275–288. van de Ridder JM, Stokking KM, Mcgaghie WC, ten Cate OT. 2008. What is feedback in clinical education? Med Educ 42:189–197. van Hell EA, Kuks JB, Raat AN, van Lohuizen MT, Cohen-Schotanus J. 2009. Instructiveness of feedback during clerkships: Influence of supervisor, observation and student initiative. Med Teach 31:45–50. Watling CJ. 2014a. Cognition, culture, and credibility: Deconstructing feedback in medical education. Perspect Med Educ 3:124–128. Watling CJ. 2014b. Unfulfilled promise, untapped potential: Feedback at the crossroads. Med Teach 36:692–697.
Medical Teacher Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/imte20
Reflections on feedback: Closing the loop a
Subha Ramani a
Brigham and Women's Hospital and Harvard Medical School, USA Published online: 08 Jun 2015.
To cite this article: Subha Ramani (2015): Reflections on feedback: Closing the loop, Medical Teacher To link to this article: http://dx.doi.org/10.3109/0142159X.2015.1044950
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
2015, 1–2, Early Online
PERSONAL VIEW
Reflections on feedback: Closing the loop SUBHA RAMANI
Downloaded by [] at 04:55 10 July 2015
Brigham and Women’s Hospital and Harvard Medical School, USA
Lately, I have been reflecting a lot about feedback in medical education. One might think this is old hat with no new avenues for exploration, but that would be far from the truth. The feedback literature is dominated by the benefits and mechanics of feedback, yet our trainees continue to lament on the deficiencies of feedback received by them. Medical students and residents report that feedback given by their teachers is both infrequent and/or ineffective (Bing-You & Trowbridge 2009; Delva et al. 2013). Why does this trend continue when so much has been written about techniques for giving feedback and more faculty development workshops are being organized on this very topic (van de Ridder et al. 2008; Krackov 2011; Krackov & Pohl 2011). My focus has turned to exploring the feedback loop; not the one where teachers give feedback, learners listen and mostly reject the feedback, they all go home and none’s the wiser. The loop starts well before the feedback conversation is planned. It begins when the teacher and learner meet for the first time, regardless of the duration of the teaching experience.
The importance of the learning environment A positive learning environment is established at that introduction where the stage is set for future feedback exchange. A congenial environment is conducive to learning, making mistakes and learning from them, honest admission of limitations on both sides and a willingness to learn from all levels; it also establishes trust between teachers and learners. The trust ensures that feedback is a two-way exchange, includes discussion of strengths and weaknesses, always with professional growth and improvement as the goal of the exchange (Krackov & Pohl 2011; Lombarts et al. 2014).
This quote is very apt when we consider how feedback is provided to learners in medical education. Once a positive learning climate is established, the obvious next step would be communication of learning goals (Chang et al. 2011). Educational leaders need to communicate goals and objectives of the rotation or course to those who teach, teachers should communicate these goals as specific behaviours to learners and learners should establish their own learning goals and communicate these to their teachers. Together, teachers and learners can calibrate their performance at various stages to determine goals achieved and those yet to be achieved.
The importance of reflection Asking students to think about their work before receiving feedback scratches up the soil in their brain so the feedback seeds have a place to settle in and grow – Jan Chappuis Encouraging self-reflection on strengths and weaknesses is an essential factor in training reflective practitioners (Cantillon & Sargeant 2008; van Hell et al. 2009; Krackov & Pohl 2011; Chappuis 2014). I like the Pendleton approach which places self-assessment at the centre of a feedback exchange (Pendleton 1984). I have found that medical trainees are overachievers and tend to be their own worst critics; frequently I end up refuting their gloomy selfappraisals expanding on and highlighting the positives. Thus, starting a conversation with self-reflection can potentially minimise anger, negative emotions and lack of receptivity to corrective feedback (Sargeant et al. 2008; van Hell et al. 2009; Delva et al. 2013). Of course, there are always exceptions to this general principle and teachers must be prepared for those.
The importance of plans The importance of learning goals Everyone is a genius. But if you judge a fish on its ability to climb a tree, it will live its whole life believing it is stupid – Albert Einstein.
Feedback serves no purpose if recipients do not list their specific strengths and areas that need improvement in terms of learning outcomes and describe professional improvement plans (Boud & Molloy 2013; Watling 2014a, b). To achieve this, feedback is best based on specific behaviours, close
Correspondence: Subha Ramani MBBS, MMEd, MPH, Assistant Professor of Medicine, Harvard Medical School, Internal Medicine Residency Program, Brigham and Women’s Hospital, 75 Francis Street, ASB 1&2, Boston, MA 02115, USA. Tel: (617) 732-6040; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/0000001–2 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1044950
1
S. Ramani
observation and aimed at motivating professional development. This completes the feedback loop. I think it’s very important to have a feedback loop, where you’re constantly thinking about what you’ve done and how you could be doing it better. I think that’s the single best piece of advice: constantly think about how you could be doing things better and questioning yourself – Elon Musk
Downloaded by [] at 04:55 10 July 2015
And finally . . . Perhaps I could conclude by simplifying the purpose and process of feedback. Those receiving feedback, teachers or learners, should be able to answer the following three questions at the end of a feedback conversation: (1) Where am I? – Calibration of performance, strengths and areas for improvement (2) Where do I need to be? – Outcomes to be achievedknowledge, skills and attitudes (3) How do I get there? – Reflection, self-assessment and action plan
Notes on contributor SUBHA RAMANI, MBBS, MMEd, MPH, is the Director of Evaluation for the Internal Medicine Residency Program at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School.
Declaration of interest: The author reports no declarations of interest.
2
References Bing-You RG, Trowbridge RL. 2009. Why medical educators may be failing at feedback. JAMA 302:1330–1331. Boud D, Molloy E. 2013. Feedback in higher and professional education: understanding it and doing it well. London, UK: Routledge. Cantillon P, Sargeant J. 2008. Giving feedback in clinical settings. BMJ 337: a1961. Chang A, Chou CL, Teherani A, Hauer KE. 2011. Clinical skills-related learning goals of senior medical students after performance feedback. Med Educ 45:878–885. Chappuis J. 2014. Seven strategies of assessment for learning. Upper Saddle River, NJ: Pearson Education. Delva D, Sargeant J, Miller S, Holland J, Alexiadis Brown P, Leblanc C, Lightfoot K, Mann K. 2013. Encouraging residents to seek feedback. Med Teach 35:e1625–1631. Krackov SK. 2011. Expanding the horizon for feedback. Med Teach 33: 873–874. Krackov SK, Pohl H. 2011. Building expertise using the deliberate practice curriculum-planning model. Med Teach 33:570–575. Lombarts KM, Heineman MJ, Scherpbier AJ, Arah OA. 2014. Effect of the learning climate of residency programs on faculty’s teaching performance as evaluated by residents. PLoS One 9:e86512. Pendleton D. 1984. The consultation: An approach to learning and teaching. Oxford, UK: Oxford University Press. Sargeant J, Mann K, Sinclair D, van der Vleuten C, Metsemakers J. 2008. Understanding the influence of emotions and reflection upon multisource feedback acceptance and use. Adv Health Sci Educ Theory Pract 13:275–288. van de Ridder JM, Stokking KM, Mcgaghie WC, ten Cate OT. 2008. What is feedback in clinical education? Med Educ 42:189–197. van Hell EA, Kuks JB, Raat AN, van Lohuizen MT, Cohen-Schotanus J. 2009. Instructiveness of feedback during clerkships: Influence of supervisor, observation and student initiative. Med Teach 31:45–50. Watling CJ. 2014a. Cognition, culture, and credibility: Deconstructing feedback in medical education. Perspect Med Educ 3:124–128. Watling CJ. 2014b. Unfulfilled promise, untapped potential: Feedback at the crossroads. Med Teach 36:692–697.
