How To Provide Helpful Feedback To Residents

Residents are constantly developing and refining their technical and cognitive skills. “But without structured, actionable feedback from mentors, residents can have difficulty knowing what specific adjustments are needed to improve,” said Jenny X. Chen, MD, EdM, assistant professor in the department of otolaryngology–head and neck surgery at Johns Hopkins School of Medicine in Baltimore. “Feedback is essential in clinical training because it supports deliberate practice—a focused, repetitive approach to skill building that’s fundamental in surgery.”

In fact, Sarah Bowe, MD, EdM, program director in the department of otolaryngology–head and neck surgery at San Antonio Uniformed Services Health Education Consortium in San Antonio, Texas, believes that feedback is the single most important component of clinical training. She echoes the sentiment Jack Ende, MD, wrote in a JAMA article: “Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all,” (JAMA. doi:10.1001/jama.1983.03340060055026).

Added Michael Orestes, MD, program director in the department of surgery at Walter Reed National Military Medical Center in Bethesda, Md., “Without clear feedback, residents often feel uncertain about what they’re doing well and what needs improvement. Residents will struggle to improve, often learning more by trial and error.”

Feedback shouldn’t be confused with “assessment,” which is a more formal evaluation of knowledge, competency, or acquired skill to determine if a trainee has accomplished a milestone or certain level of achievement during their training, said Brad deSilva, MD, an otolaryngologist in the department of otolaryngology, and residency program director, laryngology fellowship director, professor, and vice chair for education at The Ohio State University Wexner Medical Center in Columbus, Ohio.

“Feedback is designed to help residents improve, while an assessment gauges a resident’s readiness for graduation or could be their score on an annual in-service training examination,” Dr. Orestes said. This helps to determine how a program is performing on certain educational topics. 

Although hearing feedback can be difficult, ultimately trainees want to know when they did something wrong. “They appreciate being told to do something in a different way, as it may improve their skills or efficiency when performing a specific task,” Dr. deSilva said.

Nuts and Bolts

Given the importance of feedback, clinicians should be sure to provide it regularly and to tell residents to expect it. “If you only give feedback when something bad happens, then residents will dread a feedback session,” said Nausheen Jamal, MD, MBA, professor and chair of the department of otolaryngology–head and neck surgery at the University of Texas Medical Branch, John Sealy School of Medicine, in Galveston, Texas. “By knowing that feedback will be given often, residents can mentally prepare to hear what they should work on.”

When feedback is given irregularly, it can backfire and cause residents to feel like they’re in trouble—making it difficult for them to process feedback, Dr. Orestes added.

The most useful feedback is specific, timely, and delivered in a supportive manner. Specificity is key: Feedback should focus on clear, observable actions rather than vague or general statements, Dr. Chen said. For example, instead of telling a resident to work on their communication skills, provide concrete examples such as, “During your patient handoff to the nurse, you could have been more organized in delivering the patient’s post-operative plan.”

Dr. Orestes advised tailoring feedback to each resident; generic feedback isn’t very useful. For example, advice such as, “Next time, read a little more,” or “You just have to do more cases, you’ll get it eventually,” is too vague. Instead,
provide a roadmap. For example, “You were able to dissect out the superior pole this time and identified the recurrent laryngeal nerve. For your next case, let’s see if you can find the nerve without as much assistance.”

Timeliness is equally important; feedback should be given as close to the observed behavior as possible to make the connection between the action and the response more meaningful, Dr. Chen said. Deliver feedback using a non-judgmental tone and body language.

Ideally, find a private place where a resident won’t feel judged when receiving feedback, and where both parties can sit down, Dr. Orestes said. “Feedback should be more of a conversation and less one-directional,” he said.

In some instances, it may be okay to give feedback in front of peers. “It’s very dependent on the relationship of the people in the group,” Dr. Orestes said. “If several residents performed a case together and you have standard post-operative feedback, it shouldn’t be a problem. If you must convey very critical feedback, be sure to convey that in private. An exception would be to stop a hazardous action from being taken.”

Dr. deSilva agreed that providing feedback privately, in a calm setting, is typically best. But the flip side can be true as well—if someone does something well, don’t hesitate to highlight their performance and include faculty and peers so others can emulate their behavior or strive to do better.

Broaching the Subject

Starting a conversation about feedback on the right foot is key. Begin by setting a collaborative tone, asking a resident to self-assess with questions such as, “How do you think that case went?” This invites reflection and provides insight into their perspective, Dr. Chen said.

Dr. deSilva said that asking an open-ended question is often helpful, such as, What do you think you could have done better during this specific surgery or clinic day? “It’s often helpful to first understand a trainee’s perspective before providing your own assessment of their performance,” he said.

It’s also helpful to make feedback growth-oriented, rather than critical. For example, by saying, “Let’s take a minute to talk about how you can keep making progress,” you can make a conversation positive and forward-focused, Dr. Chen said. Keep feedback specific to actions or skills, rather than personal attributes, to help reduce defensiveness and make it easier to apply.

Dr. Chen tries to tailor her feedback to each learner after reflecting on her relationship with them as well as their experience and personality. While the core principles of effective feedback—being specific, timely, and constructive—remain the same, the way she presents feedback can change.

For example, some residents benefit from a more direct, no-nonsense approach, while others may need more encouragement and positive reinforcement to maintain motivation.

Dr. Chen also considers a resident’s level of self-awareness. For more senior learners who are already self-reflective, she relies heavily on open-ended questions that prompt them to assess their own performance. For those who are less confident or self-aware, she might provide more guidance upfront, focusing on strengths before discussing areas for improvement. “Ultimately, my goal is to make feedback actionable and ensure it resonates with learners, so I adjust my approach to try to meet them where they are in their development,” she said.

Overcoming Challenges

It can be difficult to ensure that feedback is well-received, especially if it addresses areas for improvement. Residents may feel defensive when receiving critical feedback, which can hinder their ability to process it constructively. “To overcome this, strive to build trust and rapport over time,” Dr. Chen said. “Fostering a supportive environment where feedback is seen as an opportunity for growth, rather than a personal attack, can reduce defensiveness.”

Another challenge is balancing the amount and type of feedback. Providing too little feedback can leave residents unsure of how to improve, while too much can overwhelm them, especially if it’s delivered all at once, Dr. Chen said. Prioritize the most critical issues and offer feedback that aligns with a resident’s developmental stage.

…strive to build trust and rapport over time. Fostering a supportive environment where feedback is seen as an opportunity for growth, rather than a personal attack, can reduce defensiveness. —Jenny X. Chen, MD, EdM

Timing can also present obstacles. “Many competing demands for our attention exist; it’s easy to complete an encounter or case and then immediately move on to the next task,” Dr. Bowe said. “But giving feedback verbally doesn’t have to take a lot of time, especially if a specific defined goal is articulated before the engagement. Another option is to consider using feedback platforms, such as myTIPreport, to capture information in real-time and make it available for a later conversation.”

While Sarah K. Rapoport, MD, assistant professor in the department of otolaryngology–head and neck surgery at Georgetown University Hospital and the Washington, D.C. Veterans Affairs Medical Center in Washington, D.C., tries to provide feedback in the moment, she also tries to gauge when that might be less effective. In those situations, she lets time pass so that heightened emotions can subside before addressing the issue and providing feedback. “My goal in these cases is to try to improve a learner’s ability to hear and internalize feedback so they can optimally receive it, internalize its value, and then apply it moving forward,” she said.

Along these lines, Dr. deSilva said that sometimes a trainee may seem to shut down or not enjoy receiving feedback. In those situations, it can be best to circle back several days later—after they’ve had time to process everything.

Additional Advice

For some clinicians, “doing the deed” can cause anxiety. “If you approach the conversation in a way that it will be an uncomfortable situation, then it will make it a less easy conversation to have,” Dr. Jamal said.

If you only give feedback when something bad happens, then residents will dread a feedback session — Nausheen Jamal, MD, MBA

Dr. Jamal begins a conversation about critical or constructive feedback in a similar way to discussing complex information with a patient. “I want to make sure I understand where the patient is coming from and what their understanding of their condition is, and then base my explanation on what they already know and understand,” she said. For residents, she will ask how they thought they did when performing a particular surgery, what they think they’ve mastered, and what steps they still find challenging.

Determine what you want to say and say it clearly; don’t beat around the bush, Dr. Jamal continued. To quote the title of an article by American academic Brené Brown, “Clear is kind. Unclear is unkind.”

Upon reflection, Dr. Chen said that most of her poor experiences giving feedback stemmed from not having built a good foundational relationship with a learner before providing feedback that’s difficult to hear. “Without a foundation of trust and respect, feedback can strain a relationship,” she said.

Knowing a resident’s thought process behind their decisions during a case can help me provide specific feedback, particularly when I was expecting a different thought process. — Sarah K. Rapoport, MD

As a resident, Dr. Rapoport found it less effective when attendings provided feedback by comparing her and her co-residents’ performances to each other rather than their own, individual progress. “Now that I’m an attending teaching my own residents, I keep this in mind and aim to provide each resident I work with feedback specific to their own performance over time,” she said. “I hope this sets them up to succeed the next time they face the same clinical decision or scenario.” 

Karen Appold is an award-winning journalist based in Pennsylvania.