The Other “F” Word

By Emma Spence, Meds '21

Aware that many would not be eager to dive into an article about Feedback, I knew that I would need to do something to captivate your attention. I hope to entice you to stay tuned at least long enough for me to share my view on feedback. Come my third year of medical school, I now realize that feedback is one of the most significant contributors to my growth and development as a burgeoning clinician. How uniquely valuable it is that I get to glean opportunities to see myself through expert eyes, to get practical insight from MDs with decades of experience, and to get an honest rating of my performance. Since I have come to value its importance so highly, I have invested significant thought into breaking down my approach to feedback, some aspects of which I hope to share here.

Feedback in medical training comes in many forms. It can look very different based on the individuals involved, the level of training, the setting in which it was evaluated and received, etc. While a sit-down meeting can be conducive to communication, sometimes a telling gaze across a room can send all-too-clear a message. Feedback can be an expressive process through exchanges with others. However, it can equally be an introspective and reflective practice carried out within one’s own consciousness. While many of these may be simultaneous and ongoing, various individuals tend to weigh differently the value of spontaneous versus elicited feedback, external versus internal feedback, and verbal versus non-verbal feedback. I believe that it is crucial to tune into all of these forms of feedback in order to optimize one’s development as a medical learner. For the purposes of this article, I will focus on elicited verbal external feedback.

I recall learning about giving and receiving feedback during the Clinical Skills course in my first year of medical school. While this learning did effectively prompt me to shift away from my previously employed “compliment sandwich” method of receiving and delivering feedback, the content felt fairly intuitive and conceptual, and I did not think too much it. It was not until clerkship that I really experienced what it was like to receive poor quality feedback. I don’t mean feedback telling me my performance was poor - I have gratefully received constructive feedback throughout my training. Rather, I mean feedback that was poor in that it did not help me to assess my performance in a way that would be useful to my development as a learner.  Some assessors would clearly have intentional, organized, pertinent and thoughtful methods of giving feedback. Contrastingly, others would simply employ the “things are fine” approach. The latter would sometimes make me mourn the wasted breath – my words in eliciting the feedback would seem futile, and I felt almost guilty having them expend their breath on an unconstructive answer. Both of these types of experiences have prompted me to appreciate that creating valuable feedback is in fact a skill –a skill that not everyone has been explicitly taught. I would like to emphasize here that I have yet to even mention the content of any feedback. This discussion has little to do with whether the feedback received is positive, constructive, or otherwise. Rather, it has to do with how effectively feedback can be elicited, delivered and received by students – the performance quality of the skill of feedback itself. 

Once I established that feedback was a key component of my learning, I decided that it was a worthwhile investment of my time. The trouble was, external feedback inherently involved individuals and elements beyond my own locus of influence. So, came the understanding that in order to acquire the caliber of feedback I sought, I would have to make the most of those things that I could in fact control. Below are a series of questions I now tend to ask myself each time I seek out verbal external feedback. As with most things, there is certainly more than one good way to approach feedback. I hope to share just one such method that I have personally found to be constructive in case a colleague might derive benefit.

Why do I want this feedback?
There are instances where we collect feedback simply because we have to, or because we feel we should. For example, at the end of a Clinical Skills encounter during pre-clerkship or to fill out one of the tens of clerkship evaluations we are all unavoidably required to submit. Beyond the program requirements, however, I find it valuable to take a moment to consider why ‘I’ want this feedback. There are occasions when we seek others’ thoughts as a means of forcing ourselves to reflect on our own performance. Alternatively, asking for a performance evaluation can force an assessor to reflect critically on our functioning, which may be valuable to get their wheels turning with regard to a reference letter, to reflect our investment as a learner, or to somehow implant ourselves in their memory before getting lost as yet another clerk rotating through their service. Sometimes we ask for feedback simply to ensure that we aren’t doing a terrible job! Often, opening a feedback discussion carries the intent of debriefing – whether about an isolated difficult encounter or a longitudinal clinical experience. Other times, admittedly, we are looking for some reassurance or a pat on the back. Evidently there is a wide variety of reasons we might seek out feedback. 
Program requirements and reassurance aside, if I can truthfully say that my motivation to receive this particular feedback is due to a genuine desire to improve, then I can move forward to these following questions. 

What am I willing to put in to receive high quality feedback?
As is frequently the case, “you often get out what you put in.” External feedback is a conversation, which inherently involves at least two people. As such, if we are expecting meaningful output from them, it is only fair that we input a similar amount of thought and effort. 

The timing of a request for feedback is important. In my opinion, if I catch a preceptor with one foot out the door on a Friday afternoon to ask for feedback, it would not be fair of me to be frustrated with a low-volume, generic response. While there is only so much control we can exert over the ever-unpredictable schedules of clinicians, one thing I do to help myself is to foreshadow my desire for a discussion. This typically helps us to later find a time and place that feels more private and less rushed. 

It is equally important to make sure you have provided the assessor with the information they require in order to give valuable feedback.  After pre-clerkship, oftentimes it is challenging for staff to keep track of your level of training – did that clerk say they were in third or fourth year? Does their school have a fourth year? Does that mean they have only done core blocks or elective placements? Why do they need this feedback? Is it simply to review whether the course objectives were satisfied or is it because this particular rotation is important regarding career choices? You know your own training, experiences and goals better than anybody else. So, I have found it really helpful to voice what my own objectives and focus-points are, which provides specific things for my assessor to comment on that are actually valuable to me and appropriate to my level of training. 

A final, very valuable, input of effort prior to seeking feedback is self-reflection. This reflective process can be quite brief. For instance, if you only worked with a staff for one day, there is not a lot to review. However, if you have worked with someone over a longer period of time, it can be a deeper dive into how you feel you have developed over recent days, weeks, blocks, etc. I have found that going in with my own assessment of my learning and performance adds meaning and calibrates whatever is subsequently shared with me. I have often found it helpful to voice these reflections (negative, positive or otherwise) to my assessor prior to them sharing their thoughts as it provides a framework as to the scope, depth and topics of commentary I am hoping for.

Are there considerations I need to make from the other person’s point of view?
Most teachers do in fact want to stimulate and contribute to the growth of their learners, and many see feedback as a key component of this process. However, it is important for us students to consider that while we are there to learn and grow – other than in controlled setting such as clinical skills or a classroom – our superiors are there to care for and keep patients alive. As such, we must be cognizant of the setting, timing and emotions surrounding our desire to learn. 

Also, when it comes to viewing things from another’s perspective, I would like to openly admit that my assessment from others’ points of view with regard to feedback has more than once been quite inaccurate – thinking a week was going terribly but finding out at the end this staff was impressed by how much he pushed me. This to say, while it is courteous and important to consider things from another’s viewpoint, avoid losing learning opportunities by shying away from seeking feedback from individuals when you think you already know their opinions. You will often be surprised how differently they see things.

How am I going to respond to this feedback? 
Responding to feedback is often a two-part process involving both an immediate and longer-term response. In the moment, feedback can spark any number of emotions from flattery, to embarrassment, to frustration or disappointment. This aspect of feedback likely is the most disparate in terms of how individuals handle themselves. One approach is to allow yourself to feel whatever emotion is stirred up in that instant, while still allowing yourself to listen to all the feedback being offered. It would be a wasted effort to go through this whole process only to not listen to what your evaluator has to share. Once the encounter has passed, you are then able to select what information you would like to carry forward with you versus what information you might leave behind. Yes, you are allowed to leave some comments behind. However, I would caution that comments which I have found myself feeling defensive about in the moment, have turned out to be some of the greatest motivators or contributors to my growth.
Ultimately, how you respond to the feedback ties in extremely closely with my first question – Why do I want this feedback? If I did genuinely seek this feedback in order to grow, then I will want to jot down the information that has been shared with me and apply the feedback that has been given.

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As mentioned throughout, these questions are by no means strict choreography to successful exchanges of feedback. These are simply some thoughts to consider as we go through our medical training that undoubtedly will be inundated with feedback (sometimes to the point of “feedback fatigue”). Ultimately, despite our best efforts, there will still be occasions where all we get back is, “things are fine” – and that is ok. I feel that if I have carried out this exercise and asked myself these questions, I have done my part in the dance of feedback. While the dance may have turned into a solo, I will have, nonetheless, invested truly meaningful reflection that contributes to my ultimate goal of growth.