The Feedback Loop

It’s often said that medicine is a lifelong learning process – that medical education never ends, and that there’s always more to discover. Although most pathologists would agree with this statement – particularly in our own field of specialty – one key aspect of learning is frequently overlooked: feedback. Do you know how to give effective feedback? Do you know how to receive it and put it to work for you? Do you know how best to use feedback to improve your work and expand your knowledge? Many pathologists have not put that much thought into feedback, and yet it’s one of the most important skills you can develop.

What sparked your interest in feedback?

Sara Jiang: I’ve spent time at Duke University as a medical student, a resident, and now as a faculty member – so I’ve had the opportunity to see many different feedback styles. And let me say: not all feedback is equal! Some people are very thorough in their responses and evaluations, whereas some do not give much information at all. I’ve been in situations where I’ve asked for feedback and the answer has been a generic, “Oh, you’re doing great! Keep up the good work. We love having you.” That may feel good to hear (and of course, it’s a nice thing to be able to say, too), but it’s not helpful for someone whose goal is to improve their skills.

When I joined the faculty at Duke as an attending, I wanted to make a real effort to ensure that I was effectively meeting the needs of my trainees. I work closely with Sarah Bean in cytopathology, so I had the opportunity to hear her speak about feedback – a subject in which she has extensive experience. Since then, we have been able to work together on developing some feedback education – and have worked together to teach it to others.

Rachel Jug: As a current trainee, I recognize the importance of receiving feedback. It’s valuable because I can use it to improve my performance. But during my training, I also get to act as a teacher to a variety of learners – for example, medical students in lectures or rotating through our department. It’s when the tables are turned and it’s my job to give feedback that I can see how difficult it is, if you haven’t had much experience with feedback exchanges. Like any other skill, you have to develop it by practicing! I’m very interested in helping people to become more familiar with – and comfortable with – feedback, because I think it helps all learners and educators better themselves.

What makes feedback so important for professional development in pathology?

SJ: No matter what your career stage, we are all learners in medicine. Our chosen field is a process of lifetime learning – and learning is at the core of feedback.

The idea of feedback in medical education goes back to 1983, when Jack Ende published his seminal paper on the subject (1). He wrote, “Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all.” I quote this regularly because I think it really gets to the heart of the matter. Feedback is a good opportunity to correct mistakes. It’s a good opportunity to reinforce the things learners and teachers are doing well. And if you don’t have feedback, you’re basically flying by the seat of your pants – something I don’t think is acceptable in a field as critical as medicine. The point of feedback is to improve our ability as doctors to deliver safe and effective patient care.

RJ: Feedback is crucial in medicine because it’s an ever-evolving field. Continuous education is vital to ensure the safety of our patients and the quality of our work. When people hesitate to give or receive feedback, bad habits go unchecked and learning opportunities are missed.

What are the main barriers to giving and receiving feedback?

SJ: I think a lot of the barriers are skill-based. People aren’t necessarily trained in how to deliver feedback – something we’re trying to help with – so they may not feel like they have the skills or the knowledge to give effective, sensitive feedback. People who are still in training may also feel like they aren’t in a position where they’re empowered to give feedback; medicine is very hierarchical and it can be difficult to get into the mindset of “critiquing” a “superior.”

I think there are logistical factors as well. For instance, we’re all extremely busy – and people often think that feedback takes a long time, so they’re afraid they don’t have time to do it. It may not always be convenient to give feedback; for instance, you might be in a room with a patient, and most people would prefer not to give (or receive) feedback in front of third parties – especially when you’re commenting on their medical treatment!

There’s also fear of the emotional aspect, and that comes from both above and below. Trainees may be afraid to give feedback to those higher up in the hierarchy because they don’t want to offend anyone. But the same is true for those of us who have climbed up through the hierarchy. We’re often afraid that the feedback we give with the intention of improving performance will instead be taken as a personal criticism. We’re all very conscious of wanting to nurture and encourage our staff and younger colleagues, which creates a fear that constructive feedback might be taken personally and trigger a negative emotional response.

RJ: Lacking an established feedback culture in your workplace can be a barrier, because feedback isn’t exclusive to the domain of residents and attendings. It should be exchanged between all members of the pathology department – physicians, scientists, techs, couriers, administrative assistants – to ensure the proper working of the department. Of course, not everyone may feel comfortable giving feedback to others whom they perceive as being higher up in the departmental hierarchy or having more or different expertise. That’s why we need to encourage the idea of “feedback culture” – because if you establish something as being “normal,” then everyone becomes comfortable with accepting commentary from everyone else. It helps to break down potential barriers to feedback exchange.

Do you have any advice on improving feedback skills?

SJ: I think you can start with small steps. One really easy way to create a feedback culture is to label feedback as such. It sounds simple – but when you ask residents whether they’re getting feedback, they often say they aren’t… whereas, if you ask the teachers, they’ll tell you they give feedback all the time. The problem is that they’re not necessarily calling it that. Even something as simple as saying, “this is feedback” gets the receiver in the right mindset. You want them to think, “Okay, I’m getting feedback. It’s time for me to listen and get myself into a receptive frame of mind.”

When I’m on service with a resident, I like to let them know I’ll be giving them feedback ahead of time. At the beginning of the week, I say, “We’re going to establish some goals now, and at the end of the week, we’re going to have a very brief instant-feedback time.” So at the end of the week when I say it’s time for feedback, their response is not, “Oh, my gosh, I’m getting feedback – it must be bad,” but rather, “This is what always happens at the end of the week; it’s an opportunity to learn.”

But how do you acquire feedback skills? That’s not something we teach in medical school – but it is something that is now part of the residency competency requirements, at least for pathology residents in the US. There’s a professionalism competency for “gives and receives feedback,” so it’s actually something residents are expected to achieve. And there are a number of tools out there to help: published articles, courses (like the ones Dr. Bean and I give), and even web-based resources (we’re developing a podcast and we created an American Society of Cytopathology Cell Talk on feedback). For those who are anxious at the idea of giving feedback, my advice is: find one small thing to say – one piece of feedback for your residents. Once you’ve done that, look for another. The more you do it, the more natural it becomes, and the more everybody begins to expect the feedback process.

RJ: My general advice would be to practice giving feedback on a regular basis. It helps to be self-reflective; consider the times you have received feedback and think about the way that people gave it to you. Try to recall the teachers you’ve had over the course of your education, their different feedback styles, and what worked well – and then try to use the best of them as role models for framing your own feedback delivery.

Do you have any tips for receiving feedback well?

SJ: Most people tend to think about receiving feedback less often. As individuals, we need to be more mindful about the way we receive feedback. Sarah Bean has a wonderful way of approaching it – she says, “Feedback is a gift. There are a few different ways to react to a gift.” In other words, you can choose what to do with it. For some feedback, you may think, “This is wonderful; it’s exactly what I needed to hear, and I’m going to put it to use immediately.” To other comments, you might say, “You know what? This is not useful to me.” And to others still, you might think, “This is kind of okay; maybe I’ll store it away, reflect upon it more, and use it later.” Approaching feedback as a gift is really helpful – not only because it gives you control over what you do with it, but also because it reinforces the fact that the person who is giving you the feedback is giving it to you with good intentions.

RJ: It’s important to consider that the optimal exchange of feedback is bidirectional. There should never be just one person giving feedback and the other receiving it. It should be an ongoing conversation. And I think that those on the receiving end should be mindful of what they’re being told, ask questions and get clarification if necessary, and reflect on it afterward. That’s how they can benefit most from it and implement constructive criticism into their practice.

How do you prefer to give feedback yourself?

SJ: A lot of us are familiar with the “feedback sandwich,” wherein one piece of negative feedback is sandwiched between two instances of positive commentary. We prefer the “ask-tell-ask” approach, which takes that sandwich model and tweaks it to make it more effective. To create true bidirectional feedback, there needs to be a learning partnership between the giver and the receiver. The “ask-tell-ask” method facilitates that by allowing an opportunity for the learner to give input:

• Ask: Here, the learner performs a self-assessment. The teacher might ask, “What do you think went well in that fine needle aspiration?” The question prompts the learner to evaluate their own performance. “I think I was able to make the patient feel really comfortable with the procedure.”
• Tell: At this point, the feedback giver reflects on what the learner has said. For instance, “I agree that you did a wonderful job of making the patient feel at ease.” It allows the teacher to reinforce the things they agree with from the learner’s self-assessment. This is also the point at which you tell them the additional components they might not have identified. “You put too much gel on the patient’s neck.”
• Ask: The second ask is to check understanding and develop a plan to act on the feedback. You might say, “Does that make sense? How can we fix this moving forward?”

Have you had any particularly good (or bad) feedback experiences?

RJ: I recall a time when I was given really good feedback. It was in the fine needle aspiration (FNA) clinic. I was doing an FNA on a patient and didn’t use a supporting hand to keep my needle steady. My attending was watching me during the consultation. As soon as we had finished with the patient and were alone in a separate room, he gave me feedback. He started by telling me the things that I had done well; then, he told me that an area of improvement would be to use my other hand as a support to keep the hand with the needle steady, and he showed me how to do it. Throughout the interaction, he was positive, friendly and respectful of me.

The next time we saw a patient together, he observed my practice again, and I used the method he had taught me. He made a point of commenting afterward on how well I had done at implementing his feedback! Ever since, I’ve thought of that as a really good example of how to give high-quality feedback. It felt like a team approach – a bidirectional conversation – and it made me, as a learner, feel like he wanted to provide me with the best possible education.

In contrast, one of the least effective pieces of feedback I have ever received was actually secondhand. An attending gave me a written evaluation and, in the comment section, they quoted another attending – someone who was commenting on my performance without ever having seen me perform my clinical duties! It was much harder for me to take that feedback seriously and to implement it, because I felt that it wasn’t really speaking to me and my abilities – and it definitely wasn’t a bidirectional exchange.

SJ: Feedback needs to be timely, non-judgmental, based on direct observation, and focused on behaviors that can be changed. I think the previous two examples illustrate this perfectly. When you’re giving feedback, it cannot be based on hearsay, because the learner is more able to trust something the teacher has seen for themselves. The attending in the first example did a wonderful job of implementing all of the components of effective feedback; the second not so much.

We often perceive feedback as part of medical education – and it’s true that much of the research on feedback has been in the context of teaching medical students and residents. But I think, no matter whether you’re in a teaching hospital or a private practice; whether you work with residents or lab staff; whether you’re just beginning your medical career or running an entire department, feedback is vital to ensure that everyone performs to the best of their ability and is able to continue lifelong learning.

Even if you don’t think you’re giving feedback, you probably are – one way or another. By being mindful of it and making an effort to do it the right way will help you at every stage of your career.

Xiaoyin “Sara” Jiang is a Pathologist at Duke Cancer Center and Assistant Professor of Pathology at Duke University.

Sarah Bean is an Associate Professor of Pathology at Duke Health, Pathology Medical Director of the Derm/Path Clinical Research Uni, and Program Director for the Cytopathology and Surgical Pathology Fellowship.

Rachel Jug is a third-year resident in pathology at Duke University, Durham, USA.