For any GP involved in teaching, the ability to give constructive feedback is essential. Negative comments about performance will haunt an individual and can harm their self-confidence.
By contrast, the ability to give good positive feedback is satisfying for both trainer and registrar and can improve confidence, clarify learning needs and lead to improvements in learning and teaching.
Feedback skills are transferable and can improve staff morale and motivation. They help make annual appraisal less threatening and even enjoyable.
Feedback skills are also useful for improving rapport with uncommunicative patients.
Preparing to give feedback
It is useful to imagine you are the person receiving the feedback and how it would feel.
An appropriate setting is essential; a busy corridor is not conducive to a personal conversation. A quiet room with the phone turned off to avoid interruption is ideal.
Timing is important; ideally it should be soon after the learning event so that details can be remembered.
Ensure adequate time is allowed between consultations for feedback. Sessions with a medical student developing their history taking skills will need longer appointments with gaps to allow for immediate feedback.
An F1 or F2 doctor calling in a supervising GP during a busy surgery may benefit from further feedback at the end of the morning. Salient points should be noted down to refer to later.
Asking permission to give feedback is a good idea and allows the students to prepare themselves.
What went well?
Traditional structured consultation skills feedback according to 'Pendleton's rules' focuses on what went well first, followed by positive feedback from observers.1
Discussion then moves onto areas that could have gone better (identified by the registrar) with self suggestions for improvement followed by suggestions from the trainer or peer group.
This approach can be used in both one-to-one training with patients and group teaching.
When asked what went well in the situation, the learner may take time to identify a specific and verbalise it. Repeating this back in their own words and checking your interpretation of it reinforces the positive.
If the response is 'I had quite good rapport with the patient', ask them to identify specifically what they did to develop that rapport. Add detail, for example: 'I noticed that you increased rapport by nodding and maintaining eye contact'.
Elicit any further examples of what went well before moving on to your own feedback.
This traditional model is supportive and discourages the learner from self-criticism.
When giving feedback it helps to give evidence and detail first, then the praise and conclusion.
When teaching in small groups registrars can be encouraged to give specific feedback.
When asking for any other thoughts or ideas about the consultation and areas that were difficult, criticism can be avoided by talking in terms of the consultation or situation, the problem or the patient's response rather than the doctor's performance.
If there were major 'red flag' questions that were missed it can be useful to direct the discussion to differential diagnoses and questions that could be asked to exclude them.
In a group situation suggestions can be invited by asking if there is anything anyone else would like to ask the patient?
It is the trainer's responsibility to ensure that one observer does not dominate the group and to stop peers from being critical by discussing the case rather than the individual's performance.
Many students use 'okay' as an instant response to revelations from patients without realising that this can be inappropriate. Teaching about the use of silence, empathic statements or nodding instead of saying 'okay' can prevent misunderstandings.
Outcome-based analysis of consultation skills allows the student to immediately describe the difficult part of the consultation and problem solve.
The student may later seek supportive suggestions from the teacher or group about alternative approaches that can be considered.
It is the responsibility of the trainer to ensure a balance of constructive suggestions and positive feedback and to introduce general consultation skills theory and research evidence to support the group's or learner's ideas (Calgary-Cambridge approach).2
Feedback relayed from a third party is more likely to be believed, for example, a receptionist reporting that a patient 'appreciated how you listened to her instead of looking at the computer'.
Writing down third-party feedback with the date and time can be effective and is useful for annual appraisals. Expert patients and patient actors are a valuable resource for providing feedback.
Written forms of feedback
Written feedback enables further reflection after a training session. Structured formats can help to identify aspects of the consultation to consider (e.g introduction, body language, eliciting health beliefs, recognising cues and hidden agendas).
Registrars who have practised consultation skills can be asked in advance if they want feedback on any particular aspect. They might choose, for example, the use of open and closed questions. Positive examples should be recorded following the same principles as verbal feedback.
1. Allow time and space for feedback.
2. Give specific examples of good points then offer praise.
3. Ask the learner to identify challenging areas.
4. Use third-party and written feedback where appropriate.
5. Encourage the learner (and observers) to reflect and identify their main learning outcome.
Finishing a teaching session it is useful to ask students to identify one main learning point to encourage reflection. It is helpful to put the learning in context, reminding learners how it can be applied to other scenarios, parts of the curriculum or other specialities within medicine.
Finally, ask for any specific feedback about your teaching. This emphasises that feedback is a two-way process, and is valuable at all stages in a career.
- Dr Miller is a freelance GP, mentor for the London deanery and medical student tutor at Imperial College, London.
This topic falls under section 3.7 of the RCGP curriculum 'Teaching, Mentoring and Clinical Supervision', www.healthcarerepublic.com/curriculum
1. Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: an approach to learning and teaching. Oxford: Oxford University Press, 2003.
2. Silverman J, Kurtz S, Draper J. The Calgary-Cambridge approach to communication skills teaching 1: agenda-led outcome-based analysis of the consultation. Edu Gen Prac 1996; 7: 288-99.