2015, 1–2, Early Online
PERSONAL VIEW
Reflections on feedback: Closing the loop
SUBHA RAMANI
Brigham and Women’s Hospital and Harvard Medical School, USA
Lately, I have been reflecting a lot about feedback in medical
education. One might think this is old hat with no new
avenues for exploration, but that would be far from the truth.
The feedback literature is dominated by the benefits and
mechanics of feedback, yet our trainees continue to lament on
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the deficiencies of feedback received by them. Medical
students and residents report that feedback given by their
teachers is both infrequent and/or ineffective (Bing-You &
Trowbridge 2009; Delva et al. 2013). Why does this trend
continue when so much has been written about techniques for
giving feedback and more faculty development workshops are
being organized on this very topic (van de Ridder et al. 2008;
Krackov 2011; Krackov & Pohl 2011).
For personal use only.
My focus has turned to exploring the feedback loop; not the
one where teachers give feedback, learners listen and mostly
reject the feedback, they all go home and none’s the wiser.
The loop starts well before the feedback conversation is
planned. It begins when the teacher and learner meet for
the first time, regardless of the duration of the teaching
experience.
The importance of the learning
environment
A positive learning environment is established at that
introduction where the stage is set for future feedback
exchange. A congenial environment is conducive to learning,
making mistakes and learning from them, honest admission of
limitations on both sides and a willingness to learn from all
levels; it also establishes trust between teachers and learners.
The trust ensures that feedback is a two-way exchange,
includes discussion of strengths and weaknesses, always with
professional growth and improvement as the goal of the
exchange (Krackov & Pohl 2011; Lombarts et al. 2014).
The importance of learning goals
Everyone is a genius. But if you judge a fish on its
ability to climb a tree, it will live its whole life
believing it is stupid – Albert Einstein.
Correspondence: Subha Ramani MBBS, MMEd, MPH, Assistant Professor of Medicine, Harvard Medical School, Internal Medicine Residency
Program, Brigham and Women’s Hospital, 75 Francis Street, ASB 1&2, Boston, MA 02115, USA. Tel: (617) 732-6040; E-mail: sramani@partners.org
ISSN 0142-159X print/ISSN 1466-187X online/15/0000001–2 ß 2015 Informa UK Ltd.
DOI: 10.3109/0142159X.2015.1044950
This quote is very apt when we consider how feedback
is provided to learners in medical education. Once a
positive learning climate is established, the obvious next
step would be communication of learning goals (Chang et al.
2011). Educational leaders need to communicate goals and
objectives of the rotation or course to those who teach,
teachers should communicate these goals as specific beha-
viours to learners and learners should establish their own
learning goals and communicate these to their teachers.
Together, teachers and learners can calibrate their perfor-
mance at various stages to determine goals achieved and those
yet to be achieved.
The importance of reflection
Asking students to think about their work before
receiving feedback scratches up the soil in their brain
so the feedback seeds have a place to settle in and
grow – Jan Chappuis
Encouraging self-reflection on strengths and weaknesses
is an essential factor in training reflective practitioners
(Cantillon & Sargeant 2008; van Hell et al. 2009; Krackov &
Pohl 2011; Chappuis 2014). I like the Pendleton approach
which places self-assessment at the centre of a feedback
exchange (Pendleton 1984). I have found that medical
trainees are overachievers and tend to be their own worst
critics; frequently I end up refuting their gloomy self-
appraisals expanding on and highlighting the positives. Thus,
starting a conversation with self-reflection can potentially
minimise anger, negative emotions and lack of receptivity
to corrective feedback (Sargeant et al. 2008; van Hell et al.
2009; Delva et al. 2013). Of course, there are always
exceptions to this general principle and teachers must be
prepared for those.
The importance of plans
Feedback serves no purpose if recipients do not list their
specific strengths and areas that need improvement in terms of
learning outcomes and describe professional improvement
plans (Boud & Molloy 2013; Watling 2014a, b). To achieve this,
feedback is best based on specific behaviours, close
1
 S. Ramani
observation and aimed at motivating professional develop-
ment. This completes the feedback loop.
I think it’s very important to have a feedback loop,
where you’re constantly thinking about what you’ve
done and how you could be doing it better. I think
that’s the single best piece of advice: constantly think
about how you could be doing things better and
questioning yourself – Elon Musk
And finally . . .
Perhaps I could conclude by simplifying the purpose and
process of feedback. Those receiving feedback, teachers or
learners, should be able to answer the following three
questions at the end of a feedback conversation:
(1) Where am I? – Calibration of performance, strengths and
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areas for improvement
(2) Where do I need to be? – Outcomes to be achieved-
knowledge, skills and attitudes
(3) How do I get there? – Reflection, self-assessment and
action plan
Notes on contributor
For personal use only.
SUBHA RAMANI, MBBS, MMEd, MPH, is the Director of Evaluation for the
Internal Medicine Residency Program at Brigham and Women’s Hospital
and Assistant Professor of Medicine at Harvard Medical School.
Declaration of interest: The author reports no declarations
of interest.
References
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a1961.
Chang A, Chou CL, Teherani A, Hauer KE. 2011. Clinical skills-related
learning goals of senior medical students after performance feedback.
Med Educ 45:878–885.
Chappuis J. 2014. Seven strategies of assessment for learning. Upper Saddle
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Delva D, Sargeant J, Miller S, Holland J, Alexiadis Brown P, Leblanc C,
Lightfoot K, Mann K. 2013. Encouraging residents to seek feedback.
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learning climate of residency programs on faculty’s teaching perform-
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Pendleton D. 1984. The consultation: An approach to learning and
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