Feedback & Reflection in

medical education
 Objectives:
What?

How? Why?

Feedback
&
reflection

Where Who?
?
When
?
 What is meant by feedback

• Feedback is a description of a student’s

performance intended to guide future
performance
 What is meant by reflection?

• Reflection: thinking analytically about a

clinical situation or activity, for better
understanding of the situation and using the
results to improve the future.
 Objectives:
What?

How? Why?

Feedback
&
reflection

Where Who?
?
When
?
 Why feedback & reflection?

What happens without constructive

feedback & reflection?
 Why feedback & reflection?
What happens without constructive feedback
& reflection?
Mistakes go unrecognized

Required level of competence is not achieved

 Why feedback & reflection?
What happens without constructive feedback
& reflection?
Mistakes go unrecognized

Required level of competence is not achieved

 Why feedback & reflection?

Feedback is the fuel that drives

improved performance.

Eric Parsloe
 Why feedback & reflection?

So, what are the advantages?

• Show learners the level of their performance.
• Address the weaknesses and deficiencies of
the learners.
• A stimulus for further learning and training.
• The addition of reflection to feedback
promotes deeper learning
ACGME
NARS 2017
 Objectives:
What?

How? Why?

Feedback
&
reflection

Where Who?
?
When
?
 Who gives feedback?
• Everyone:
– Teachers
– Peers

– Any healthcare colleague (e.g. nurses)

– Patients.
 Who performs reflection?
• I reflect on:
– My own actions, performances
– The situations I face.
 Objectives:
What?

How? Why?

Feedback
&
reflection

Where Who?
?
When
?
 When & where to give feedback?

• Types of feedback & their timing:

Brief feedback

Formal feedback

Major feedback
 When & where to give feedback?

• Types of feedback & their timing:

Brief feedback

 Given while demonstrating physical examination or

someone’s presentation of a patient’s history. The
teacher makes useful suggestions.
 Example: ‘‘‘Let me give you some feedback, let me
show you a better way to distinguish the S4 from the
S1”.
 Given liberally whenever possible.
 When & where to give feedback?

• Types of feedback & their timing:

Formal feedback

 The teacher sets aside a period of time, usually 5 - 20

min to deliver useful feedback to the learner.
 Examples: to a doctor following an outpatient
teaching encounter, OR to a ward team following the
presentation of a case OR after a medical mistake.
 Formal feedback should be employed routinely after
learning interactions with patients.
 When & where to give feedback?

• Types of feedback & their timing:

Major feedback

 Scheduled sessions to provide feedback; the learner

knows that feedback will be given.
 At the midpoint of every clinical rotation.
 Always held in private and typically last for 15 to 30
minutes.
 When & where to do reflection?

Reflection: accompanies feedback. Whenever

possible.
Types of reflection & their timing:
For action

In action

On action
 When & where to do reflection?

Reflection: accompanies feedback. Whenever

possible.
Types of reflection & their timing:
For action

In action

On action
 Objectives:
What?

How? Why?

Feedback
&
reflection

Where Who?
?
When
?
 How?
• How to give feedback?
• How to receive feedback?
• How to perform reflection?
 How to give feedback?
• How to give effective, constructive
feedback?
– Time
– Place
– Subject
– Language & manner
– Self-reflection first
– Amount
Examples of feedback
 How to give feedback?
• How to give effective, constructive
feedback?
Time:
After the event as soon as possible to
maximize benefit
 How to give feedback?
• How to give effective, constructive
feedback?
Place:
– may be in front of others or private,
according to the situation.
 How to give feedback?
• How to give effective, constructive
feedback?
Subject:
• Use well-defined goals as the subject
of feedback.

• Feedback should include an action

plan for future development.
 How to give feedback?
• How to give effective, constructive
feedback?
Language & manner:
• Have a tactful and non-threatening manner.
• Use language that is non - evaluative and non-
judgmental
• Be specific, relevant and descriptive
 How to give feedback?
• How to give effective, constructive feedback?
Self-reflection first
– Recommended during formal & major feedback.
– Use questions as ‘‘What went well, and what
could you have done better?’’
– Reflection brings up the points the teacher wants
to make, so that:
• points made by the learner, no overwhelming list
• softening the perception of feedback on sensitive
topics, such a medical mistake.
 How to give feedback?
• How to give effective, constructive
feedback?
Amount:
Give feedback in small, digestible
quantities
Not too much and not too little.
 How to give feedback?
Feedback models:
The “feedback sandwich”:

1. Begin with the positive feedback

2. Then introduce the constructive or negative
feedback
3. Close with statement which builds up the
learner’s trust and comfort
 How to give feedback?
Feedback models:
The “feedback sandwich”:
• Applicable in everyday clinical practice.
• Avoid using this method continuously, as it
might lose its effectiveness.
 How to give feedback?
Feedback models:
The “feedback sandwich”:
 How to give feedback?
Feedback models:
The “feedback sandwich”:
• Example
“I noticed you made the patient & relatives feel very
comfortable while you explained the test to them, and
your explanation was very clear.
It would have helped further if you had given them patient
information leaflets, as at times they were looking a bit
overwhelmed.
However, you have set a time for meeting with them
again, and this will give you the opportunity of answering
any questions and giving the leaflets.”
 How to give feedback?
Feedback models:
The Pendleton model:
1. Ask the learner what went well.
2. Tell the learner what went well.
3. Ask the learner what could be done
differently or improved.
4. Tell the learner what could be improved &
how.
 How to give feedback?
Feedback models:
The Pendleton model:
1. Ask the learner what went well.
2. Tell the learner what went well.
3. Ask the learner what could be done
differently or improved.
4. Tell the learner what could be improved &
how.
 How to receive feedback?
• Embrace it as a learning
opportunity.
• Be a good listener
• When in doubt, ask
• Think before responding
• Be a good sport & show
appreciation
• Be proactive
How to perform reflection?
How to perform reflection?
How to perform reflection?
N.B. Any medical or training situation can be
enhanced by the use of reflection and feedback
as follows:
— A teacher can give feedback to the
learner about that performance
— The learner can reflect on her/his
performance
 Identify feedback/reflection in this
example
• A medical teacher observes that a medical
student had difficulty in prioritizing
between urgent symptoms and minor
complaints during clinical encounter.
• The teacher draws the attention of the
student to this defect in his performance.
 Identify feedback/reflection in this
example
• The student will think about what he did right
or wrong, what caused the confusion and what
to do next to improve his practice.
• The student will write down the list of clinical
problems, prioritize them according to
importance, and present them to the teacher
after each encounter.
• The process should always end with a plan of
action.
 Barriers to effective feedback
• Generalized non-specific feedback.

• Fear of upsetting colleagues

• Defensive behaviour when receiving feedback

• Physical barriers: improper time, place or space

• Personal agendas

• Lack of confidence
 Question 1
• Which of the following is true about the formal
and major feedback?
a. Given liberally and not scheduled
b. Given by the learner about his performance
c. Can be combined with self-reflection first
d. Include three items: what happened, analysis and
plan.
 Question 2
• A medical student is studying for an exam which is
held next week. He thinks about his previous exam
and decides to avoid his past errors in the ways of
studying and answering the exam. What is the type of
reflection in this case?

A. Reflection for action

B. Reflection in action
C. Reflection on action
 Question 3
• Every time the students examine patients at the ward, their
coach holds immediately after they leave the ward a meeting
with them to draw their attention to good points the students
made and what should be improved. What is the best
description for this action?

A. Brief feedback

B. Formal feedback
C. Major feedback
D. Self-feedback
 Question 4
• After the student inserted an intravenous cannula, the
coach asked him “What do you think went well, what
could be further improved and how”. What best
describes this statement?
A. Major feedback
B. Pendleton technique
C. Reflection on action
D. Sandwich feedback
 Question 5
• Which of the following is true about the Pendleton
model?
A. Good points of the learner are given at first and at end
of feedback
B. Good points and those to improve are elicited by open
questions
C. Points to be improved are given at the end of feedback
D. Points to be improved are given at the start and end of
feedback