Our feedback model is broken. Here’s how to change it.

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I recently gave two talks at my residency program, one on health care innovation and another on intimate partner violence. I know little about each topic, but my goal as presenter was merely to know more than each person in the room. To require residents to give talks as newly-minted “experts” on topics creates a paradox of generating both anxiety and excitement in presenters. This paradox could be phrased in a dozen ways, as between fostering authority versus humility, or submission versus empowerment. I thought about these tensions after receiving structured “feedback” on my talks. In both cases, I had done a “great job engaging the audience” but failed to deliver “tangible take-home points.” In the language of the banking model of education, at the end of the talk, the students, while engaged, remained poor. The concept of feedback in medical education has become as fluid, omnipresent and ultimately empty as the concept of professionalism. Here is why.

1. Feedback is unidirectional. Despite attempts at equalizing power dynamics in medicine, the vast majority of feedback is unidirectional. The theory goes that the trainee has a list of items to learn, and needs a supervisor to assess their competence. While this model works for many concrete tasks (i.e. assessing procedural skills such as taking blood pressure, putting in a central line), it falls short of assessing most tasks in the modern health care environment. Did the trainees’ patient get better? Did the nursing staff trust the trainee? Similarly, in an educational setting, what did the students learn? How do they conceptualize the topic differently? What are they going to do with the take-home points?

2. Feedback is episodic. There is an initiative at my hospital to encourage educators to use a card outlining “one-minute feedback.” The theory is that, over time, dozens of data points will create a larger mosaic that represents a trainee’s performance. An alternative educational theory is that trainees learn by actively processing information out loud, and by creating a language to monitor their own blind spots. In other words, the concepts of critical reflection and metacognition are lost within a model of fast-food model of feedback.

3. Feedback stifles curiosity. During seven years of medical training, I have endured hundreds of feedback sessions, debating the fine-points of whether I was truly a 3 or 4 out of 5 on the scoring rubric. I nearly always leave somewhat annoyed, as if I am medication being verified, with the hidden goal is to ensure accurate documentation of my status. Only once did I leave a feedback session with renewed curiosity for medicine. The well-regarded Pediatrician asked me two questions. First, “How do you think you come across to others?” And second, “Based on your rotation, what ideas do you have for how we can deliver health care?”

Every time I meet with a medical student, I ask these same two questions. Within ten minutes, I learn more than any rubric or feedback session can tell me. I share my experiences with ideas for health care reform, commit to continuing a conversation beyond the confines of the rotation, and truly try to understand what drives them in medicine. We need traditional feedback in medicine, but we also need to acknowledge its’ limitations, both in theory and practice. At root, our feedback model is based on a banking model of education, long recognized in educational circles as deficient. In practice, the mosaic of disparate evaluations is no substitute for its opposite: a bidirectional, longitudinal, and investigative approach.

Tom Peteet is an internal medicine resident.

Image credit: Shutterstock.com

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