Giving feedback
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7200.2 (Published 26 June 1999) Cite this as: BMJ 1999;318:S2-7200
- Jennifer King, chartered psychologist and management consultant
Providing feedback is central to training doctors. Jennifer King considers theoretical and practical aspects of this important skill for all who teach or appraise
“I shall always be a flower girl to Professor Higgins because he always treats me as a flower girl … But I know I can be a lady to you because you always treat me as a lady, and always will …”1
Consultants and general practitioner trainers play Pygmalion-like roles in developing able trainee doctors and stimulating their performance. Some consultants and trainers treat their junior staff in a way that leads to superior performance. Others, like Professor Higgins, unintentionally treat their trainees in a way that undermines their efforts and fails to develop their potential as doctors. There is a growing body of evidence that demonstrates the power of positive expectations - the so called Pygmalion effect.2
Trainees are hungry for regular and constructive feedback,3,4 but one of the commonest concerns of educational supervisors is their ability to “give effective feedback, both praise and constructive criticism.”5 Despite feedback being an integral part of training it is an area for which many consultants and general practitioner trainers feel ill prepared.6
This led us to develop a tailored training programme in appraisal skills and constructive feedback to bring out the best in trainee doctors. The two questions most often asked by consultants on our course are how to keep trainees motivated and how to give difficult feedback constructively.
Feedback and motivation
Most people have a basic need to know how well they are doing; and the expectation of success is fundamental to motivation and effort.7 Both increase when we expect to succeed but decrease or cease when the goal is perceived as almost certain or impossible. Similarly, behaviour theory suggests that positive reinforcement of a specific behaviour increases the chances that the behaviour will be repeated. So as the trainee performs, the trainer should select specific aspects of the performance for praise and highlight these to the trainee. Unfortunately, what tends to happen is that only the poor aspects are identified. This may have the desired effect of reducing future occurrences of this behaviour, but it also produces the undesirable effect of increasing anxiety, even fear, and reduces the trainee's openness to further learning and evaluation.
Factors that affect motivation in tasks 8
People are motivated when they are:
Clear about what is expected
Supported by managers or supervisors
Recognised for their efforts
Contributing in a way which is positive and recognisable
Free to express their views and ideas
Challenged in a way which helps them to develop and be more creative
Here is the nub of the feedback challenge: how to draw trainees' attention to their less satisfactory aspects while maintaining or even increasing their desire to learn, improve, and seek further evaluation. Psychological research shows that six factors have a significant effect on job involvement, effort, and, ultimately, productivity (see box).8 These factors contribute to a positive psychological climate at work. All these factors are embodied in, and facilitated by, effective feedback.
Criteria for feedback
People are motivated when they are:
Descriptive - of the behaviour rather than the personality
Specific - rather than general
Sensitive - to the needs of the receiver as well as the giver
Directed - towards behaviour that can be changed (“You're too tall” is unhelpful)
Timely - given as close to the event as possible (taking account of the personõs readiness, etc)
Selective - addressing one or two key issues rather than too many at once
Making it effective
Effective feedback requires a combination of qualities, skills, and some structure. We routinely ask consultants and trainees to describe their own experiences of receiving feedback and to identify the characteristics that made it a positive or negative experience. The most commonly cited positive features include mutual respect, specific praise or criticism, a genuine desire to help, and allowing time. Negative features typically include public humiliation, comments on personality, no opportunity for a two way discussion, lack of personal interest, too general, and too little too late.
Some argue that their most formative experiences were the result of very negative feedback and that providing constructive feedback smacks of “mollycoddling.” In the face of increasing stress, diminishing morale, and recruitment crises these arguments are hard to sustain. And challenge and support are not opposite ends of a spectrum: challenge alone provides a potentially punitive environment; support alone does not push people to develop.
Athletics coaches and good managers know that they can boost a person's performance by giving them a suitable challenge combined with an expression of confidence. When the challenge increases, so must the support. This is a key principle for effective feedback.
Skills of effective feedback
Ultimately, feedback is about communication. The skills are generic: active listening; asking a balance of open, reflective, facilitating, and closed questions; challenging; and summarising. Giving feedback is not just to provide a judgment or evaluation. It is to provide insight. Without insight into their own strengths and limitations, trainees cannot progress or resolve difficulties. Thus, the key skills are to listen and ask, not, as is often the temptation, to tell and provide solutions. Compare ineffective and effective feedback:
“You need to sort out your bleep — you're impossible to contact.”
with
“Tell me more about the problems you experience when you are on-call”
Similar skills apply when giving positive feedback. Speaking in generalities (“You seem to be progressing well”) is not as helpful as giving specific examples:
“You are particularly good at giving bad news to relatives. You take your time, and listen well to their concerns.”
Structure for feedback
Another common difficulty is structuring a feedback discussion. In the early 1980s a method was developed to help doctors to develop their consultation skills.9 This method is invaluable for any feedback discussion, formal or informal:
The trainee is asked to start by identifying his or her own strengths
The trainer reinforces these and adds further strengths
The trainee is asked to identify areas for improvement
The trainer reinforces these, adding further areas if necessary.
The pitfall is to be pressurised to start at stage 4 to “get the worst over with.” This immediately puts the trainee on the defensive and potentially negates any subsequent positive feedback. The structure works on the simple principle of an emotional bank balance - withdrawals cannot be sustained without credits in place first. It also embodies, once again, that crucial balance of support and challenge. It does not allow either party to downplay strengths or to duck difficult issues. It is a model that is tried and tested in general practice training and with consultants in educational supervisor roles.
Defensive reactions to feedback
Person receiving feedback
Blaming - “It's not my fault. What can you expect when the patient won't listen?”
Denial - “I can't see any problem with that”
Rationalisation - “I've had a particularly bad week” “Doesn't everyone do this?”
Anger - “I've had enough of this”
Person giving feedback
Obligation - “I'm duty-bound to tell you this”
Moral high ground - “It's for your own good”
Burying and fudging - Taking a long time to get to the point and covering many irrelevancies
Minimising - “Don't worry, it's not such a big deal. Everyone does it at some time”
Colluding - “You're probably right, perhaps I am overreacting”
Reactions to feedback
The skills and structure described here are designed to minimise adverse reactions to feedback and ensure that the experience is constructive. Nevertheless, a variety of defensive reactions can occur, and it is important to learn some strategies for dealing with them. It is not only the receiver of feedback who can become defensive: the person giving the feedback can also manifest similar reactions.
Trying to tear down defences is not constructive - they are there for a reason. There are various strategies for reducing or eliminating defensiveness. The effective approach is the four stage, structured feedback described above. But if defensiveness persists or suddenly occurs the following approaches are useful:
Name and explore the resistance - “You seem bothered by this. Help me understand why
Keep the focus positive - “Let's recap your strengths and see if we can build on any of these to help address this problem”
Try to convince the trainee to own one part of the problem - “So you would accept that on that occasion you did lose your temper”
Negotiate - “I can help you with this issue, but first I need you to commit to …”
Allow time out - “Do you need some time to think about this?”
Allow time out - “Do you need some time to think about this?”
Keep the responsibility where it belongs - “What will you do to address this?”
Feedback skills training
Our experiences with trainers and trainees have shown clearly the merits of some specific approaches to feedback training. The most effective elements have been
Involving real volunteer junior doctors
Using video recording to reinforce the skills practice
Modelling the feedback skills and structure during the practice sessions
Wider applications
Feedback skills are generic. They can be used not only in the context of formal educational supervision, but daily with colleagues and staff, in committee and departmental meetings, and in all training situations. Education must be learner centred, and feedback is at the core of this process. If educational supervisors can adopt some of these principles and skills, then perhaps Pygmalion will no longer be a mythical character.