I had just completed a three hour workshop for medical students on feedback and reflection. The context for the workshops was contentious; the students were suspicious of the motivation of the school leadership for mandating these sessions. I was merely the facilitator. Like a cuckoo I was given a series of rooms, of sizes great and small for the thirty or so students I had each time. This time we had been in a clinical lab and it had been like a game of sardines.
Reaching the end I was delighted that the session had been well received and nobody had thrown rotten eggs at me. A couple of students came to ask sensible questions and as I dealt with them I noticed the observer, a significant lead in the medical school, hovering to speak to me too. I responded to the students and as they left, the professor approached.
“Wanted to give you a bit of feedback,” he said. I smiled and nodded, pleased that he had witnessed the success of the session, in a politically fragile time for the school. As an external facilitator I was keen to do my best by both the school and the students but that was not easy, given that the two entities were almost at war.
“Yes,” he continued. “You need to come out of the corner where you were, so that they can see you properly. First ten minutes you were squished up against the flip chart.”
I have learned over the years that feedback in medicine is of the “no news is good news” type: if I don’t hear back, it’s because they liked it; they only get in touch when they have something to criticise. Why on earth should this person have adopted a different approach?
I thanked him, realising it was pointless to mitigate myself by highlighting that I had been trapped there by the small room and clinical equipment around me, said I would take his suggestion on board and look for other ways to deal with the inadequate space I had been given.
Feedback in clinical education is still an area where I consider great learning is needed. What to a consultant on a busy round can be direct and honest feedback, can to a junior, from a different generational culture seem to be aggressive, sharp and full of blame. What matters to a sister, with 25 years experience, can seem outdated and harsh to a novice nurse just beginning their career. Apart from generational differences, which reflect society’s beliefs, the impact of the culture of medicine and the NHS affects how we deal with feedback.
As the prevailing theories of learning impact how we educate and support learners, so too feedback and how we use it changes with time and experience. As learning and training progresses from a didactic, expert centred position to a more facilitative, learner centred one, we can focus on the language we use during feedback conversations to maximise the relationships we engender in our educational work. Please note that in the following examples I use the words ‘trainer’ and ‘learner’ here although I am aware that somewhat bizarrely we have different terms for novices and experts in different professions within the NHS.
The language of feedback in medicine is influenced by the language of medicine itself, so it is often absolute even when the action it is describing was not. For example a trainer might say: “You upset her,” to a learner about a patient. We do not know that the learner did upset the patient – they may have been upset already about something else. And the absolute statement may well result in the learner feeling guilty, a failure and ashamed. Any learning from this exchange may relate to the avoidance of this trainer in future, or even worse, the avoidance of the activity.
The trainer might instead say, “Did you notice the patient began to cry when you said that her illness was terminal? What else might you have thought about saying or doing at that point?” This is more invitational, may encourage two way consideration of the event between the trainer and learner, and could result in a greater degree of open reflection.
Some areas of biomedical science are absolute, but many areas of medical practice are not. Trainers who stop and think about the way they phrase their feedback comments might find that a more questioning style can lead to reflective discussion and deeper learning. It may also strengthen the relationship and understanding between trainer and trainee.
Another influence on medical (and interestingly police) language is externalisation of causal action, which can also be seen as abdication of personal responsibility. When feedback starts with, “You…” this can instantly push the learner into defensiveness as they think that some form of blame is coming: “You did not do…., You forgot…, You can’t…, You haven’t….”
Imagine hearing statements like that every time you have an educational conversation?
The solution to this is to own our statements. We can instead say: “I noticed that you did not….; I was asking myself…; I wonder what the relatives…; and I am worried about….” After such an observation we can follow with a question: “Were you aware of that? What did you notice? Why had you decided to do…? and How did you think that would…?”
If we own our statements, and start them with the word ‘I’ there is less likelihood that learners will think we are blaming them, and more chance they will engage with us and think more deeply about their practice. This is sometimes called Advocacy Enquiry.
Some forms of science seek to generalise and this creeps into feedback too. How often have we heard (or been told): “You’re hopeless; This is always a problem; The whole thing was a mess.”
Are these statements always true? Very often they are not. We respect evidence based research and practice, which avoid generalisations and deal with specific findings. So we should endeavour to do the same in the way we phrase our feedback conversations. So for the above, maybe the following statements are more appropriate: “That was a difficult intubation and I can see you struggled there. I had to take over because……but let’s look at what you struggled with and how you would do it differently next time.” Or: “I see that you have had several problems with this now and instead of carrying on observing another, why don’t we go to the simulation lab/discuss the reasons why it might be problematic” or something else constructive. Or “I asked you to take part in this stage of the procedure because I had been impressed with your other work. This was clearly a step too far, and there were many issues with what you did before I took over. However, there are ways you can use this to learn,” and we can refer to books, e-learning, videos of procedures and simulation.
Conversations are two way. One way to engage someone in conversation is to share something about our experience and ask them something about themselves. Similar principles can work in education and training. As a trainer we can conduct a useful conversation by sharing observations, thoughts, experiences and other perspectives, by considering consequences and by offering solutions: “I noticed…” (observation), “I think…” (thought), “I used to/have had a similar…” (experiences), “I wonder what others…” (other perspectives), “I am concerned..” (considering consequences) and “I would like to suggest…” (solutions).
We know that formative, developmental conversations are effective in clinical teaching. Feedback should be to that end. Judgement, especially of global competence, is not required except in end of placement reports. The training and assessment system is ever developing and so must the way that feedback is offered. Trainees are desperate for our wisdom and experience, so we should share as much as we can with them. And we need to remember that good news is as important as bad, when it comes to people learning and developing and holding on to what they do well.