Why Medical Educators May Be Failing at Feedback

IN THE 25 YEARS SINCE ENDE 1 PUBLISHED THE SEMINAL ARticle on feedback in clinical medical education, many of the concepts have been verified and repeatedly emphasized. However, physicians participating in needs assessments for faculty development frequently cite feedback as an area for improvement. Considering the provision of feedback as a competency is quite appropriate, because feedback is an essential skill for learner improvement. Without effective feedback, learners struggle to achieve defined goals. Despite the focus on feedback, learners may still perceive a lack, even when explicitly informed that feedback is occurring. The stark difference between what teachers think they are delivering and what learners think they are receiving begs the question: are medical educators failing at promoting effective feedback? Some evidence indicates that feedback is not being provided effectively. Learners still complain about not receiving enough feedback. Verbal interaction analysis indicates that the feedback dialogue is too teacher centered and is skewed toward predominantly the positive or neutral. Feedback may be provided at a low cognitive level using basic and descriptive facts, precluding active engagement of the learner. Students’ dissatisfaction with feedback may reflect a greater desire for praise than for constructive information to help them learn. Desires for mainly positive feedback may become a worsening trend as the “Millennial Generation” enters US medical schools. This generation has been broadly characterized as being raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback. These studies suggest that educators might not be providing learners with effective feedback. Possible reasons are use of incorrect measures of success (eg, Likert-type student satisfaction scales) or insufficient faculty development programs. Such arguments tend to focus on external factors (such as increased productivity pressures) or teacherbased behaviors. The feedback dialogue has been overly centered on the role of the teacher while underemphasizing the role of the learner. As such, 3 potential reasons may help account for failing at feedback: poor ability of learners for selfassessment, overpowering influence of affective reactions to feedback, and lack of adequately developed metacognitive capacities. There is increasing evidence that physicians, as a group of professionals, have little ability to accurately self-assess performance and typically tend to overestimate abilities. This distorting cognitive process could be the result of a strong need to protect self-image. Physician-learners may be poor at assessing their own capabilities; even worse, the most deficient performers may be least aware of their lack of competence. A dangerous medical professional is one who is unaware of what he or she does not know and lacks the skills and insight necessary for self-assessment. Learners who tend to overestimate their own abilities may be surprised when they receive feedback incongruent with their self-perceptions. This conflicting feedback could generate more of an emotional reaction than an unemotional review of the facts, driven by feedback lessons unconsciously stored in memory from years past, possibly even from childhood experiences. Learners could view negative feedback as a personal attack. Since learners are motivated to defend their egos and often prefer information that supports their positive self-views, these attacks on the ego can trigger negative emotional reactions such as guilt, anger, or self-doubt, often at an unconscious level. These emotions can in turn block any useful feedback from reaching the learner at some cognitive level, creating an insurmountable barrier. Learners with distressing reactions to feedback tend to devalue it as not useful. Damage to the learner’s self-image by constructive feedback could lead to learners using cognitive mechanisms to protect themselves from narcissistic injury (eg, outright denial, distorting information). Discounted feedback would not result in improved learner performance. Learners with more positive self-esteem and stronger egos may seek both positive and negative feedback, whereas learners with lower self-esteem may seek only positive feedback. The latter may avoid feedback interactions as a selfprotective mechanism.