Feedback in Medical Education

Definition/Introduction

The Merriam-Webster dictionary defines feedback as "the transmission of evaluative or corrective information about an action, event, or process to the original or controlling source" or "the return to the input of a part of the output of a machine, system, or process." The definition has acquired a more specific meaning in education, specifically medical education. Over the last few decades, feedback in medical training has obtained special importance and attention due to its growing importance in education. Our better understanding of how we learn helped us realize the importance of feedback in the educational process.

Feedback has been a topic of study for decades. Many authors have presented their ideas on effective feedback, and multiple definitions have been developed in the literature (Brendan, 2018).[1] Until March 2019, there were more than 14,000 publications on feedback in PubMed. More than 10,000 publications focus on feedback in medical education, 7305 in the last 10 years and 4793 in the previous 5 years. There are 810 review articles on feedback in medical education. More than half of these reviews have published dates from 2010 to 2015.[2] 

Feedback is central to medical education in promoting learning and ensuring the meeting of standards.[3] Our knowledge about medical education is expanding in various directions, but numerous questions remain.

• What do we need to know more about feedback in medical education?
• What are the challenges?
• Is our use and application of medical knowledge as vast as our knowledge?
• Has the knowledge about medical education extended to all the users (teachers) level?
• Are we achieving better educational outcomes from knowing more about feedback?

These questions and others will be addressed in this topic on feedback. 

Components of Feedback

For appropriate feedback to be delivered, it has to have a basis in an accurate evaluation, which the learner receives in a positive self-directed environment.[4][5] Then, the feedback provider should discuss and guide what the next step or the next level to achieve would be. This process is aided by the facilitation of how to get there.[6]

A summary of the components includes:

1. Observation of performance: Thorough and detailed observation is the basis for accurate evaluation and feedback. Feedback providers must observe the learners' performance critically to formulate their assessment. The crucial observation is an educational skill that needs development and continuous improvement.[7]
2. Evaluation of performance: Learners' performance levels must be accurately evaluated to provide valuable feedback. Based on the accurate assessment, feedback providers can guide and facilitate learners' progress to the next level of performance.
3. Guidance to the next level of performance: Guiding the learners to improve performance to the next level is an essential component of feedback. The guidance includes describing the next level of performance in detail and relating it to the current level. It also includes discussing the importance and relevance of the next level to the goal of education as part of adult education.
4. Facilitation of performance improvement: After discussing the next level of learning, feedback providers should facilitate this journey, including educational resources, learning activities, or a timeline for the learning level.

Types of Feedback

There are many styles of feedback and proposals for application, and many studies support the benefits of these styles.[8][9][10] For interested educators in practice, this is a helpful resource to refer to when needed. But for the average educator, this is overwhelming. Some questions to consider include:

• What style is good or better, and to what situation or need?
• How do these styles apply, and to whom?
• What differentiates feedback and evaluation? 

The classification of feedback types may be done for various purposes. Feedback can be classified into different types depending on the purpose, content, process, and mode of delivery. 

Process and Settings of Feedback

Formal feedback

Formal feedback is planned, structured, and scheduled feedback. It is usually conducted at midrotation or midcourse to assist learners in optimizing their learning in the remaining part of the rotation. It can also occur at other times, such as at the end of the educational activity, after a significant educational event, or after observing a substantial learning deficiency. Most of the recommendations, elements, and requirements of feedback focus on this type.[11]

Informal feedback

Informal feedback is short, immediate, and focused. It usually takes place during or immediately after educational activities.[12] It facilitates and enhances the learning experience while it is taking place. It mixes easily with traditional teaching or training. The difference between feedback and instruction in these situations is that feedback should focus more on principles, concepts, and patterns than particular facts or events. Also, feedback should guide and facilitate the progress of the learning process.

Purpose of Feedback

Constructive feedback

Constructive feedback is task-focused feedback that aims to enhance the learning experience. Ideally, all feedback should be constructive.

Inspiring feedback

Inspiring feedback aims to motivate learners to enhance their motives and optimize their self-confidence and achievement potential. It has proven to be a powerful tool in education and is one of the most influential and essential elements of leadership.

Corrective feedback

Corrective feedback is short, frequent, task-focused feedback that aims to correct frequent or significant mistakes or below-normal performance.[13]

Breadth of Feedback

Formative feedback

Formative feedback is a short, ongoing type of feedback that is given frequently during learning to facilitate and improve the learning experience while it is happening. It follows the same principle of formative assessment regarding the details and content.[14]

Summative feedback

Summative feedback follows similar details and content of the summative assessment, in addition to the guidance and facilitation of feedback. It usually occurs at the end of the educational event or major step. It focuses on overall performance, concepts, and patterns. It is structured and planned.

Delivery of Feedback

Sandwich feedback

The term derives from the fact that 1 layer (usually the weak points of feedback) becomes sandwiched between two layers of strength points or encouragement. It is a common style of providing feedback. It is a natural and traditional way of providing insight to make it acceptable and well-perceived. Significant discussions, reviews, and criticism have been in the literature on this style.[15][16][17][18][19] It is not an ideal or highly valuable style. However, it is a simple and convenient way for many feedback providers. Educators should not be discouraged from using sandwich feedback if this is what they know the most. However, they should be encouraged to expand and improve their feedback styles.

Pendelton feedback

This feedback style came from Pendleton et al and was described in their book "The Consultation: An Approach to Learning and Teaching. Oxford University Press, Oxford." It is of high educational value, comprehensive yet straightforward, dialogue-based, learner-centered discussion, and easy to reproduce. Medical educators claim that it is more likely to motivate adults to learn. The central concept of this style is that the discussion starts with and focuses on the learner's input. Then, the feedback provider shares the educator's view.

It starts with the positive or strong points and then shifts to the weaknesses or points of improvement. So, the educator starts the feedback by asking the learner about their perception of what went well. Then, it is the educator's turn to provide insight. A discussion of improvement points occurs in the same way. Then, an action plan for improvement is made. 

Feedback, Coaching, and Mentoring

Can one compare feedback and providing coaching at the same time? To a great extent, yes. Over 1480 PubMed publications include coaching and feedback in the study. Coaching is based on closely observing performance and evaluating performance levels, strengths, and weaknesses. Coaches work with the trainees to improve their performance by guiding them to the next level, which is done by eliminating their shortcomings and strengthening their strengths. The trainee and lead run the process and are facilitated by the coach. According to Whitmore (2002), coaching believes that the trainee has the answers to their problems; this is the same principle of learner-centered education. Mentorship is often used in medical education and is similar to coaching but with some differences. Mentorship usually focuses on the long-term objectives, ultimate learning outcomes,  and opening learners' broader horizons. While coaching tends to focus more on current time performance and how to improve it. 

Feedback and Evaluation

There has been frequent confusion between feedback and evaluation among people participating in education; this is not unexpected. This question is asked and discussed in many educational activities, courses, workshops, and conferences. Evaluation is a well-known concept, tool, and process conducted routinely in education. When feedback is inadequate, it is mainly composed of assessment. Hence, there is confusion about the difference between the 2. Evaluation is the core and backbone of feedback. Without proper evaluation, no other parts of meaningful feedback are deliverable. When the evaluation process and result are discussed with the learner in a dialogue style, with advice and guidance on improving the performance and facilitation of this move, it becomes feedback.

Issues of Concern