We all remember our first experiences seeing patients during medical school and wondering “Am I doing this right?” During medical school hours upon hours were spent buried in books, journals, and occasionally attending lectures, to build a base of knowledge that would allow us the privilege of providing care to patients once in the clerkships. But knowledge of medical facts is only one facet of what it takes to be a physician and most of what we learned during our medical education and training was learned while caring for our patients. Without the guidance and constant feedback from teachers in medical school and residency, the practice and art of surgery cannot be fully learned. Therefore, students and residents undoubtedly need and have an unquenchable thirst for feedback about their performance. It is our duty as their teachers to provide them with constant, quality feedback at every step of their education and training.
We give feedback every day while teaching clinical reasoning, operative skills, patient interviewing skills, etc., but students and residents often don’t perceive these teachable moments as feedback. They want and need feedback about their performance beyond “dissect there” or “you forgot to order their aspirin”. They often need to hear “I’m going to give you some feedback…” to recognize that you are providing some suggestions about whether they are performing well and where they need improvement. Feedback is also more easily recognized by learners when there is dedicated time at the end of a task that is devoted to it, such as a debriefing session at the end of an operative case or after a day seeing patients in clinic. Quality feedback is not only measured on established goals for performance, but also based on direct observation of a task, is specific and detailed, and is focused on behaviors that can be changed. Good feedback also needs to be timely and repeated over a period of time to reinforce good performance and remediate areas of weakness. Providing feedback seems like an easy task, but for many of us it can be challenging because of time constraints, high patient loads, and lack of training about how to give effective feedback which translates into our students not getting adequate amounts of feedback. (Figure 1)
Figure 1: Common causes of inadequate feedback in medical education
At the University of Michigan, we created a Minute Feedback System that allows students on the surgery clerkship to request daily feedback from residents and faculty about their performance at the end of each day via an email-based survey platform. It not only improved our students’ perception of receiving adequate amounts of feedback during their clerkship rotation, but it also provided us a unique glimpse into the content of feedback that we were giving to our students. We analyzed over 2000 episodes of feedback over a 1-year period and found that around 80% of the feedback given by our surgery residents and faculty to 3rd year students on the surgery clerkship was encouraging, but non-specific. An example would be: “Great job. Interested and engaged. Keep working hard and feel free to ask questions and get involved.” Sure this feedback might make the student feel better about themselves but it lacks specifics which prevents the student from knowing what it was they did “great” that day and should continue to do, and what they didn’t do that prevented them from being perceived as being “involved”. It’s a missed opportunity for both the learner and the teacher. Only around 20% of the feedback we analyzed from the Minute Feedback System was considered effective feedback in that it contained specifics as to what the student was doing well or specifics about areas where they could improve. Comments such as: “Make sure you start and end the stitch below the dermis, and avoid unnecessary harsh handling of the tissue” was considered effective feedback. This type of feedback is tangible for the student and the teacher in that the student can practice their needle placement and the faculty can focus on teaching better tissue handling the next time the student sutures.
Too often when students or residents ask for feedback we are caught off-guard and give the typical response of “You’re doing great.” Be ready to offer some suggestions for improvement. Its ok to give similar feedback to multiple learners, especially if there is a particular point you want to get across or a particular skill on which most students need improvement (i.e. always leaning over the incision too much when closing skin). In academic medicine we often teach a continuous rotation of students and residents and the goals and objectives of the rotation are generally presented to the learners at the beginning of each rotation. These goals and objectives can be a useful guide for teachers to generate topics for effective feedback that are relevant for that particular clinical service.
We have used the data from our electronic feedback system in efforts to improve both the quantity and quality of feedback through educational sessions for our faculty and residents. Having examples of effective and ineffective feedback for each resident and faculty as well as their response rates to student requests allows for continuous improvement process. We have seen the use of the Minute Feedback System remain constant over its 2 years of use and the overall students’ and residents’ perception of receiving adequate feedback has increased over that time period. Residents have also become more adept at asking for specific feedback about their performance, particularly in the area of operative skills. Taken together these things have helped to move the culture of feedback beyond the typical “Good job, read more.”
Hughes DT, Leininger L, Reddy RM, Sandhu G, Ryszawa S, Englesbe M. A novel Minute Feedback System for medical students. Am J Surg. 2017 Feb;213(2):330-335. doi: 10.1016/j.amjsurg.2016.11.042. Epub 2016 Dec 2. PubMed PMID: 27939007.
Shaughness G, Georgoff P, Sandhu G, Leininger L, Nikolian VC, Reddy R, Hughes DT. Assessment of clinical feedback to medical students via an electronic feedback system. Journal of Surgical Research. (Accepted for publication, 07/2017)