Definition/Introduction

The definition of feedback in the Merriam-Webster dictionary is "the transmission of evaluative or corrective information about an action, event, or process to the original or controlling source," or "the return to the input of a part of the output of a machine, system, or process." The definition has acquired a more specific meaning in education, specifically medical education. Over the last few decades, feedback in medical training has obtained special importance and attention due to it's growing importance in education. It was our better understanding of how we learn that helped us to realize the importance of feedback in the educational process.

Feedback has been a topic of study for decades. Many authors have presented their ideas on effective feedback with multiple definitions developed in the literature (Brendan, 2018).[1]  Until March 2019, there were more than 14000 publications on feedback in PubMed. More than 10000 publications focus on feedback in medical education, 7305 in the last ten years, and 4793 in the previous five years. There are 810 review articles on feedback in medical education. More than half of these reviews have published dates from  2010 to 2015.[2] Feedback is central to medical education in promoting learning and ensuring the meeting of standards.[3] Our knowledge about medical education is expanding in various directions. But, what do we need to know more about feedback in medical education? What are the challenges? Is our use and application of medical knowledge as vast as our knowledge? Has the knowledge about medical education extended to all the users' (teachers) level? Are we achieving better educational outcomes from knowing more about feedback? These questions and others will be addressed in this review of feedback. 

Components of Feedback

For appropriate feedback to be delivered, it has to have a basis in an accurate evaluation, the result of which the learner receives in a positive self-directed environment.[4][5] Then the feedback provider should discuss and guide what would be the next step or the next level to achieve. This process is aided by the facilitation of how to get there.[6]

A summary of the components includes:

1. Observation of performance - Thorough and detailed observation is the basis for accurate evaluation and feedback. Feedback providers have to observe with critical eyes the learners' performance to formulate their assessment. The crucial observation is an educational skill that needs development and continuous improvement.[7]
2. Evaluation of performance - Learners' level of performance has to be accurately evaluated to provide valuable feedback. Based on the accurate assessment, feedback providers can guide and facilitate learners to move to the next level of performance.
3. Guidance to the next level of performance- Guiding the learners to improve performance to the next level is an essential component of feedback. The guidance includes describing the next level of performance with some detailed description and relating it to the current level. It also includes discussing the importance and relevance of the next level to the goal of education as part of adult education.
4. Facilitation of performance improvement - After discussing the next level of learning, feedback providers should facilitate this journey, including educational resources, learning activities, and or timeline for the learning level.

Types of Feedback

There are many styles of feedback and proposals of application. There are also many studies to support the benefit of these styles.[8][9][10] For interested educators by practice, this is a helpful resource to refer to when needed. But for the average educator, this is overwhelming. What style is good or better, and to what situation or need? How to apply these styles and on whom? What differentiates feedback and evaluation? These are all questions heard from many colleagues.

Classification of feedback types may follow various purposes. Feedback can classify into different types depending on the purpose, content, process, and mode of delivery. No classification has universal acceptance. In this activity, all the possible variations will be included and briefly reviewed. It is useful to be familiar with the various types. 

Classification according to:

1- Process and settings of feedback[11]:

A.) Formal feedback. It is a planned, structured, and scheduled feedback. It is usually conducted at mid-rotation or mid-course to assist learners in optimizing their learning in the remaining part of the rotation. It can occur at other times, e.g., end of the educational activity, after a significant educational event, or after observation of a substantial learning deficiency. Most of the recommendations, elements, and requirements of feedback focus on this type. 

B.) Informal feedback. It is a short, immediate, and focused feedback. It usually takes place during or immediately after the educational activities.[12] It facilitates and enhances the learning experience while it is taking place. It mixes easily with traditional teaching or training. The difference between feedback and instruction in these situations is that feedback should focus more on principles, concepts, and patterns than particular facts or events. Also, feedback should guide and facilitate the progress of the learning process.

2- Purpose of feedback:

A.) Constructive feedback. It is task-focused feedback that aims at building and improving the learning experience. Ideally, all feedback should be constructive.

B.) Inspiring feedback. This feedback aims at motivating learners to enhance motives and optimize the self-confidence and achievement potentials. Inspiring feedback has proven to be a powerful tool in education. Inspiring is one of the most influential and most essential elements of leadership.

C.) Corrective feedback. It is short, frequent, and task-focused feedback aimed at correcting frequent or significant mistakes or below normal performance.[13]

3 - Breadth of feedback:

A.) Formative feedback. It is a short ongoing type of feedback that is given frequently during learning to facilitate and improve the learning experience while it is happening. It follows the same principle of formative assessment in terms of the details and content.[14]

B.) Summative feedback. It follows similar details and content of the summative assessment, in addition to the guidance and facilitation of feedback. It usually takes place at the end of the educational event or major step. It focuses on overall performance, concepts, and patterns. It is structured and planned.

4 - Delivery of feedback:

A.) Sandwich feedback. The term derives from the fact that one layer (usually the weak points of feedback) becomes sandwiched between two layers of strength points or encouragement. It is a common style of providing feedback. It is a natural and traditional way of providing insight to make it acceptable and well perceived. There have been significant discussions, reviews, and criticism in the literature on this style.[15][16][17][18][19] It is not an ideal or highly valuable style. But it is a simple and convenient way for many feedback providers. Educators should not be discouraged from using sandwich feedback if this is what they know the most. But they should be encouraged to expand and improve their feedback styles.

B.) Pendelton feedback. This style of feedback came from Pendleton and his group and described in their book "The Consultation: An Approach to Learning and Teaching. Oxford University Press, Oxford". It is of high educational value, comprehensive yet straightforward, dialogue-based, learner-centered discussion, and easy to reproduce. Medical educators claim that it is more likely to motivate adults to learn. The central concept of this style is that the discussion starts with and focuses on the learner's input. Then the feedback provider will share the educator's view.

It starts with the positive or strength points then shift to the weaknesses or points of improvement. So the educator will start the feedback by asking the learner about own perception of what went well. Then, it is the educator's turn to provide insight. A discussion of improvement points occurs in the same way. Then an action plan for improvement is made. 

Feedback, Coaching, and Mentoring

Can one compare feedback and providing coaching at the same time? To a great extent, yes. Over 1480 PubMed publications include coaching and feedback in the study. Coaching has its basis on close observation of performance and evaluating the performance level, strengths, and weakness. Coaches work with the trainees to improve their performance by guiding them to the next level, which is done by eliminating their shortcomings and strengthening their strengths.  The trainee and lead run the process and are facilitated by the coach. According to Whitmore (2002), coaching believes that the trainee has the answers to their problems; this is the same principle of learner-centered education. Mentorship is often used in medical education and is similar to coaching yet with some differences. Mentorship usually focuses on the long term objectives, ultimate learning outcomes,  and opening learners' broader horizons. While coaching tends to focus more on current time performance and how to improve it.  

Feedback and Evaluation

There has been frequent confusion between feedback and evaluation among people participating in education; this is not unexpected. There are many educational activities, courses, workshops, or conferences where this question is asked and discussed.  Evaluation is a well-known concept, tool, and process conducted routinely in the field of education. When feedback is inadequate, it is mainly composed of assessment. Hence the confusion of the difference between the two. Evaluation is the core and backbone of feedback. Without performing a proper evaluation, no other parts of meaningful feedback are deliverable. When the evaluation process and result are discussed with the learner in a dialogue style, with advice and guidance on improving the performance and facilitation of this move, it becomes feedback.

Issues of Concern

There are multiple articles and publications providing reviews and conclusions of the research done in the field. Studies offer various tips and recommendations on many details and parts of feedback. Tips and studied aspects included institutional culture for feedback, group participation of feedback, gender variations in perception of feedback, extended effects of feedback on preparing for educators and leaders, and experiences with various itemized instruments used for feedback. All of the knowledge obtained is useful and valuable. A good part of it is directed to specialized educators and educational institutions to optimize their use of feedback concepts and tools.

Feedback for Daily Users

Most of the current structured educational activities and programs have feedback or debriefing as an essential part, which is for a variety of reasons. For most adult learning, training, and educational activities, learners expect to learn and perform what they learned after the course, workshop, or skills lab. Their goal is to learn the best from these activities to use what they learned in their profession. During the learning activity, they want to know their performance level and how they can improve it.

Therefore, providing feedback is a skill and practice that everyone in the education field needs it.  But, what do users in medical education need to know about feedback? What feedback style they have to use in their daily educational activities? The literature and publications are extensive to review and might sometimes be overwhelming or even confusing. Do they have to be experts in feedback? Do they have to use all the up-to-date knowledge about feedback? What are the most commonly needed knowledge and skills of feedback? What is the most important or core component of feedback, knowledge, and abilities?

To answer these questions, we have to review the current challenges in feedback practice. 

Challenges in Feedback

There are many challenges in using feedback at multiple levels, starting from knowing, reading, and studying feedback to seeing and measuring the educational outcomes from using the feedback.[20] A review of these challenges will be discussed here with comments and opinions on how to handle these challenges. 

1 - Feedback underuse:

A common issue of feedback is that it often gets skipped in educational activities. This omission happens for a variety of reasons. Some of these reasons are busy clinical schedules, unplanned time or setting, unnecessary delays, undermind importance, lack of skills in providing feedback, and other reasons. Raising awareness of the importance of feedback in medical education, enhancing cultural and institutional feedback practice, regular faculty development activities, proper and advanced planning of providing feedback, the inclusion of feedback in the educational curriculum, and regular re-evaluation of the progress in enhancing the practice of feedback are among the solutions to raising the level of using feedback.   

2 - Generality and brevity:

Many feedback providers use brief and general feedback. Terms like "good job," "perfect," "well-done," and other similar brief phrases have frequent use in suboptimal feedback. These terms and descriptions are inspiring and encouraging, but otherwise, have minimal feedback and educational value. Learners need to know what parts of their performance were high or low and why. They need to know how to optimize the high performance and improve the low performance with guidance and improvement efforts. Complete feedback is an essential component of education.

3 - Delayed feedback:

The feedback that is far from the time of performance time is of much less value than the immediate feedback. Depending on the type and purpose, feedback given soon after a performance is of higher educational value. It relates well to the events, contains enough and specific details, and has strong corrective influence. In a group performance and feedback, immediate debriefing has high educational value. The exception of this rule is the summative feedback given for a term training or extended courses in which enough observation and evaluation are necessary before providing meaningful feedback.

4- Misperception[7][20]:

This issue is one of the most challenging issues in providing feedback. Learners often misperceive their feedback and feel low when informed of their weak points, leading to avoiding feedback or justifying their performance. All efforts should be to facilitate learners' perception of feedback as an opportunity of learning, almost like one to one coaching. Offering giving feedback rather than forcing it, using dialogue rather than monologue feedback, giving the learner a leading role in their feedback, and choosing the right setting for feedback are all helpful points for the proper perception of feedback.

 5 - Improper setting:

Feedback is often, unfortunately, given on the go, in the presence of others, in a rush, or when the learner is not aware and/or prepared. All of these circumstances are unfavorable settings for meaningful feedback. A busy clinical schedule with patients' care priorities often dictates such situations. It is a strong recommendation that feedback is scheduled and planned for in advance and that a debriefing time of a few minutes is done routinely after important clinical activity with an educational component.[21]

6 - Acceptance / rejection:

Acceptance of feedback by learners is one of the most challenging and limiting factors. Learners would like to know how good their performance and find it challenging to accept weaknesses. This case is especially true when imposing the feedback on them. It becomes much easier when learners request and seek feedback themselves.

Clinical Significance

The importance of feedback has received extensive emphasis on medical education literature. Medical educators consider feedback as the cornerstone of medical education.[8] Its delivery and effectiveness is an area of discussion and ongoing efforts in real medical education practice. Technology will likely contribute a significant role in feedback in the near future. Feedback is evolving, and innovative objective feedback methods are necessary for medical education. New technologies will likely play a significant role soon.[8]

Nursing, Allied Health, and Interprofessional Team Interventions

Feedback is vital for nurses as it can help improve efficiency, knowledge, and teamwork. It is now routine in most nursing departments to provide regular feedback. 

Nursing, Allied Health, and Interprofessional Team Monitoring

Feedback and Evaluation

There has been frequent confusion between feedback and evaluation among people participating in education; this is not unexpected. There are many educational activities, courses, workshops, or conferences where this question is asked and discussed.  Evaluation is a well-known concept, tool, and process conducted routinely in the field of education. When feedback is inadequate, it is mainly composed of assessment. Hence the confusion of the difference between the two. Evaluation is the core and backbone of feedback. Without performing a proper evaluation, no other parts of meaningful feedback are deliverable. When the evaluation process and result are discussed with the learner in a dialogue style, with advice and guidance on improving the performance and facilitation of this move, it becomes feedback.