Resident’s Cubicle: Providing Useful Feedback

Alex Shillingburg, PharmD
Clinical Specialist BMT/ Hematologic Malignancy
WVU Healthcare, Morgantown, WV

Believe it or not, another residency year is nearing its end. For residents and program directors, ResiTrak®’s friendly and frequent reminders will begin pouring into inboxes. As you begin the task of working through the enormous pile of self-, experience, and end-of- year evaluations, it is important to ensure you are providing quality feedback.

Effective feedback is a two-way street; the preceptor and the resident must be able to both give and receive constructive comments. This article focuses on the aspect of providing feedback from two perspectives: the preceptor’s perspective of appropriately evaluating the resident’s performance and the resident’s perspective of providing useful critiques for the preceptor, evaluating the learning experience, and appropriately self-evaluating.

Preceptors: Providing Feedback

A conventional approach to providing feedback is the “sandwich method,” which involves opening with positive comments, then discussing areas for improvement or any negative comments, and closing with something positive. Although this approach is not incorrect, it hardly scratches the surface of the components needed to provide quality feedback.

High-quality feedback should be concrete, specific, useful, timely, and frequent. Simply stating positives and negatives does not let residents know what they did well or in what area they can improve. The feedback should be actionable and useful. Comments such as “That was a really good job,” “Your presentation needs work,” and “You did that wrong” are not feedback at all because they will leave residents wondering, “What specifically should I do more or less of next time based on this information?” Residents won’t know what was good or wrong about what they did and, most importantly, how to fix it.

In my experience, there are five common mistakes that even seasoned and effective preceptors make.

Making Observations
Observations and details about what the resident actually did are very important pieces of effective feedback; however, observations alone lack the most crucial aspect of feedback—assessment. If an entire evaluation is filled with statements like “The resident led three topic discussions with the team,” “The resident presented a patient case at medicine grand rounds,” and “The resident attended rounds daily,” there is no way to determine how well or poorly the resident performed. Each of these statements should be followed with an assessment of how well the task was performed by the resident and specifically identify positive accomplishments or areas that need improvement. For example, “The resident attended rounds daily and was punctual and prepared for every patient. He provided thoughtful suggestions and consistently picked up on key issues with very complicated patients. His follow-up post rounds improved greatly throughout the experience as he became more comfortable with the team’s workflow. His communication with the team was excellent, and his input was very well received. He quickly became an effective member of the team.”

Making Assumptions
Making assumptions about why residents behave in a certain way can alienate or offend them. Receiving assumptions as feedback can result in residents reacting defensively or losing confidence. If a behavior needs to be corrected, it is best to state the actual behavior you observed and how that deviated from the desired behavior. For example, an ineffective statement would be “During the guest lecture, the resident was bored and uninterested.” This statement is a judgment, not an observation. A more effective and less subjective statement would be “During the guest lecture, I observed the resident displaying inattentive behaviors such as texting, staring around the room, and making eye contact with other residents/students. These behaviors display a lack of respect for the presenter and will not be tolerated in the future.”

Providing Only Summative Feedback
Feedback is most useful in changing and shaping a resident’s performance if it is provided frequently and as close as possible to when the behaviors or tasks occurred. Receiving feedback only at the conclusion of a rotation is almost the same as if you went into your supervisor’s office for your annual review and were informed that you are being fired because you have been incorrectly documenting your interventions for the past 10 months, even though you were never told that you were documenting incorrectly and would have corrected this practice immediately had it been brought to your attention. The same concept holds true for resident learning.

A good example of timely and frequent feedback can be seen in most video games. If you fail in Angry Birds or Guitar Hero, you can immediately start over—often from where you left off—improve your strategy, and try again. Games are built to reflect and adapt to our changing need, pace, and capacity to learn. Today’s learners are accustomed to this type of rapid feedback and adaptation.

Giving Advice
As teachers and preceptors, we too often automatically give advice without first ensuring that the resident understands and accepts the intitial critiques and feedback. In doing this, we often unintentionally cause residents to feel increasingly insecure about their own judgment and to become dependent on the advice of experts, which can result in panic about what to do when either varying advice is received from different people or no advice is available at all.
• You need more examples in your article.
• You might want to use a lighter baseball bat.
• You should have gone to PubMed for this question.

These three comments are not feedback; they are advice. Unanticipated advice like this seems unnecessary at best and unhelpful and annoying at worst. If the reason for the advice is not given first, the natural response of the resident would be to wonder, “Why are you suggesting this?”

To make the above statements more effective when providing feedback, make sure the resident understands the critique.

• The points in your article are unclear in some places. Maybe you could try adding a few more examples.
• You keep dropping your shoulder when you swing, causing you to hit pop-ups. You may want to try using a lighter baseball bat.
• The answer you gave is too vague. More specific data from primary literature are needed to properly answer this. Next time you might try using PubMed.

If your ratio of advice to feedback is too high, try asking the resident, “Given the feedback you received, what ideas do you have about how to improve?” This approach will help the resident build greater confidence and autonomy.

Grading or Evaluating Versus Giving Feedback
For the majority of our lives as learners, we have been programmed to rely on grades as a measure of our performance. Though it is important to assess the quality of the end product, it is most meaningful to understand why a grade was assigned, whether acceptable or unacceptable. Some examples of unhelpful evaluation statements to avoid include
• This presentation is weak.
• Good work!
• Your formulary review is better.
• I’m really pleased with your medication use evaluation poster.

These comments make value judgments. They assess, commend, or criticize what was done. There is little or no feedback provided and no actionable information about what occurred. As a result, the resident only knows that someone has placed a high or low value on what he or she did.

By adding additional detail to these comments, they can be reworked into effective feedback that the resident can use to progress.
• This presentation is weak. The topics you presented do not intuitively flow, making it difficult to follow. The evidence that you presented did not support your conclusions, and you missed a key factor in making treatment decisions.
• Good work! Your word usage was more precise in this paper than in the previous one, and I was able to clearly understand the reasoning for your treatment selection.
• Your formulary review is improved. You included logistic considerations and sought input from nursing and scheduling. You provided an accurate cost comparison with the two alternative treatments in this scenario. I appreciate that you formulated your own recommendation and supported it with your data and research.

The most common reason cited for not using the above methods to provide feedback is that there is no time for this extensive process. Essentially, “no time to give effective feedback” means “no time to promote learning.”

Residents: Providing Feedback

All of the components of quality feedback previously discussed also apply to residents when they provide feedback to their preceptors and directors.

Evaluating Your Preceptor
The most difficult part for residents evaluating preceptors is to provide ongoing feedback. The relationship dynamic between the trainer and trainee does not often lend itself to the trainee providing any type of in-the-moment feedback about the preceptor’s performance. One way to address this would be to focus on how the preceptor’s performance affects the resident’s personal experience rather than on his or her overall ability as a preceptor. For instance, to compliment without sounding condescending, talk about how certain things have specifically helped you improve your practice. To deliver critiques, make suggestions to correct behaviors that would help you to improve your learning, such as “I feel that more frequent topic discussions in the beginning of the rotation would help improve my understanding,” or “Could you walk me through your prerounding process? I struggle learning new areas and find it helpful to hear my preceptors work through profiling their patients out loud because it shows me how to think about this special patient population.”

When evaluating your preceptor at the end of the rotation, refrain from commenting on him or her as a person and instead focus on his or her precepting style, actions that you found helpful, and actions that would benefit from improvement. Don’t be afraid to provide constructive and useful comments; a wishy-washy evaluation is as ineffective for preceptors as it is for you. Be careful, however, not to critique things that are out of the preceptor’s control, such as operational requirements. Be sure to point out times when the preceptor went above and beyond what you would have expected or when he or she failed to meet your expectations and why.

Learning Experience
I find the evaluation of the learning experience to be the most difficult. The structure of the experience is strongly dictated by the preceptor’s position and the pharmacy practice model within the preceptor’s institution or that particular area. Differentiating the experience from the preceptor also can be difficult when there is only one preceptor for a certain experience. Make an effort to focus on the pieces of the experience that can be manipulated, such as the content of topic discussions, the responsibilities you had, the activities you performed, and the goals and objectives of that rotation and whether they represent the experience you had expected. Do you feel that the things you learned and the experiences you had were representative of what that rotation should be? For example, a rotation in oncologic infectious disease should include several key pathogens and provide you with an adequate foundation for treating infections in immunocompromised patients regardless of which institution you are in or by whom you are taught.

Self-Evaluation
As a resident, one of the most crucial pieces of feedback is the self- evaluation. Self-reflection is vital to continuing your professional development beyond the residency training program. As a resident, you are evaluated constantly, but as a practitioner you receive formal feedback very infrequently. The task of evaluating your own performance and improving your practice relies on high-quality and accurate self-assessment. It is worth reiterating that the most important part is to assess how well you performed tasks, not simply what you accomplished. The benefit of practicing self-assessment during residency is that this along with the preceptor’s assessment of you will help you achieve a more realistic view of your actual performance. If the preceptor’s and resident’s assessments are similar, then the resident can be confident in knowing that he or she is able to accurately self-assess. The problem occurs when they differ from one another. If you find that your self-evaluation is rated consistently higher than your preceptor’s, seek input from your preceptor to identify your deficiencies and develop a plan to improve the quality of your practice. If your evaluation is consistently lower than your preceptor’s, then you may need to focus on building self-confidence. If your preceptor is impressed by your performance, ask what specifically motivated him or her to give you high marks and work to recognize your own strengths.

Consistently providing meaningful and effective feedback is crucial to the success and development of each resident and of the residency program. Although evaluations, rotations, or administrative responsibilities can be fatiguing and interfere with providing quality feedback, remember the tips discussed in this article and the vital role feedback plays in developing good clinical pharmacists, pharmacy preceptors, and healthcare professionals.

Special thanks to my residency program coordinator, Justin Hare, PharmD, for providing a preceptor development course on delivering feedback.

Suggested Reading

Wiggins, G. Seven keys to effective feedback. Feedback for Learning;2013:70(1):10-16.