Failing at Feedback?

In the last post, we discussed a some background and general tips on feedback, focusing on the  seminal article by Jack Ende, MD.  Unfortunately, despite all of the hype and hoopla surrounding feedback skills, learners still complain about not receiving enough feedback.

Problems with feedback identified in some studies include:

Too teacher-centered
Too much positive skew
Low cognitive level (fails to engage learner)

So why are we failing at feedback?  Perhaps the problem lies with the learner and not the teacher.  In a 2009 article titled “Why Medical Educators May Be Failing at Feedback” Bing-You and Trowbridge offer an alternate view on our failure and suggestions for improvement.  In their article, they highlight 3 key problems with the learners:

1. Poor ability for self reflection

2.  Overpowering influence of affective reactions to feedback

3.  Lack of adequately developed metacognitive capacities

Lets take a look at each of these.

Physicians are notoriously bad when it comes to self-reflection.  We tend to overestimate our abilities.  Just look at the difference between pilots and surgeons on the perception of the effects of sleep deprivation.  Even worse, the most deficient performers may be have the least insight into their incompetence.

So what happens when these learners are faced with negative feedback?  Pure emotion.  The feedback becomes a personal attack.  The feedback may trigger emotions such as guilt or anger.  The learners unconsciously fall back on ego defenses (denial, distorting information) that prevent a fair assessment of the feedback.  Knowing this, it makes sense that learners who have negative reactions to feedback find it less useful.

Learners also need strong metacognitive skills to appropriately process feedback.  Metacognition is a the process of “thinking about thinking.”  Reflection is a valuable metacognitive skill that students can use to critically evaluate the feedback and apply the needed changes.  A lack of this skill probably accounts for some of the overconfidence displayed by learners.

So how do we overcome these barriers and get through to the learners?

We need to recognize the affective component of feedback.  Knowing that negative feedback will likely invoke some degree of ego-defense, we can use guided reflection to help our students process the information at a metacognitive level.  Using follow-up activities to reinforce the positive changes may also help overcome the negative emotions.

There is a growing body of literature about how to teach metacognition.  In emergency medicine, we constantly practice procedures.  Why not teach metacognition early?  Practice with the metacognitive skills students will increase their self awareness and, hopefully, their self-assessment skills.

We need to take another look at feedback.  Efforts to improve feedback need to take these learner factors into account.  We owe it to our learners and our patients.


Bing-You RGTrowbridge RL.  Why medical educators may be failing at feedback.  JAMA. 2009 Sep 23;302(12):1330-1. PMID: 19773569 [PubMed – indexed for MEDLINE]

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