Giving feedback to medical students and trainees: rules and realities.

One of the commonest requests that medical educators get from clinical colleagues is to run training sessions on how to give feedback to students and trainees. Personally, I have a mixed reaction when I receive an invitation to do this. It is always good to know that clinicians are taking their teaching role seriously. At the same time, the requests often seem to be based on a naïve assumption that the skill of giving feedback to trainees can be mastered just by learning some simple educational techniques, rather than being developed as part of an ethos of trust, respect and mutual challenge. To improve the quality of feedback, you really need to address both. Guidance from the literature on giving feedback is fairly consistent. The purpose of feedback is to promote self-regulation in trainees, through helping them to recognise any discrepancies between what they are doing and what they ought to do. There are various sets of rules for giving feedback. The best-known are “Pendleton’s rules”, named after the psychologist who helped to formulate them. According to these rules, feedback should always follow certain fixed stages: first, the learner and then the teacher should state what was done well; next, the learner and then the teacher should say what could have been done differently; and finally the two of them agree on a joint action plan for improvement. These rules have the merit of emphasising that the learner should always speak first. However, they have come in for some criticism because of their rigid and formulaic nature. They have also been caricatured as a “kick-kiss-kick” method (not to mention ruder descriptions). Other sets of rules are somewhat more sophisticated in this respect, and are now more commonly taught. One of these, the “SHARP 5-step feedback tool”, appears in Box 1. It has been designed for use in simulation laboratories, but is applicable to clinical work as well. In the hurly-burly of the hospital ward or consulting room, it can be hard to remember, let alone apply, even a five-step approach. Learning there often happens opportunistically and the teaching has to be rapid. In these circumstances, it is more useful for teachers to hold on to some basic conversational principles instead. These include the guidance that feedback should be based on observation; be nonjudgemental and specific; focus on behaviours; elicit thoughts and feelings; and include suggestions for improvement For example, a statement like “you didn’t seem very sympathetic” is far less helpful than saying: “I noticed the patient had tears in her eyes, and I wondered whether you saw them and considered saying anything in response.” This kind of careful, respectful approach has been validated by research.