In search of meaningful feedback conversations
Expectations for feedback are high. It is considered a reference‐standard pedagogical practice that, when done well, promises to support both learning and professional development.1, 2 The challenge for educators and learners is that the promises of feedback often remain unfulfilled, in part because various forces can repel both learners and faculty members from routinely engaging in meaningful feedback conversations. Recent research suggests that, for clinician teachers, self‐assessment followed by feedback may provide a useful spark for igniting these conversations. What we do not know is whether the use of self‐assessment does anything more than formally signal the opening of a feedback event. By providing useful insight about the learner's perspective, Moroz et al. build on the nascent body of work exploring how human motivation influences feedback.
Various forces can repel both learners and faculty members from routinely engaging in meaningful feedback conversations
Participants in this study were keenly aware that feedback should be timely, specific and credible. They were also well versed about the culprits that can rob feedback of its impact. Despite efforts to circumvent some of these challenges, such as allotting protected time for sessions and permitting learners to seek feedback from trusted teachers, learners still perceived that both the process and the resulting feedback were often subpar. Years of focus on feedback in medical education have raised both our aspirations for feedback and learners’ expectations, but have they influenced the likelihood that feedback will affect performance improvement? Have they diminished learners’ ambivalence about feedback? The findings from this study suggest that the answers to both questions may be no. After analysing participants’ experiences through the lens of self‐determination theory, Moroz et al. found that no participant was intrinsically motivated to engage in feedback conversations and that only one resident was even at the ‘integration’ end of the spectrum. Learners are not easily fooled by substandard feedback and participants’ extrinsic motivations may reveal growing resentment about formulaic feedback interventions.
Years of focus on feedback in medical education have raised both our aspirations for feedback and learners’ expectations
There may also be larger forces at play. Self‐determination theory both recognises that competence, autonomy and relatedness are ‘universal psychological needs… essential for optimal development and functioning’ and acknowledges that the socio‐cultural environment significantly impacts intrinsic motivation. Learners develop their skills in a culture awash with messages about competence, confidence and autonomy; medicine is also a culture of time pressures, waiting times and competing demands. Because of these, learners perceive that – even early in training – they work independently with limited direct observation. Even if they are observed more frequently than they realise, they perceive that medical training has become less of an apprenticeship in which they are regularly observed by a master physician, and more of a partnership in which they learn through the provision of autonomous service to their patients and to their programmes.7, 8 When a faculty observer appears, learners are often taken aback. In response, they may act as learners by ticking boxes rather than behaving as physicians by performing clinical tasks as if they were unobserved. For learners, therefore, feedback, and the direct observation that should accompany it to enhance its credibility, are often perceived as something from which to graduate, rather than as something to seek and integrate.
Participants’ extrinsic motivations may reveal growing resentment about formulaic feedback interventions
In an effort to ensure that feedback occurs regularly, medicine's learning culture tends to formalise feedback interactions between teachers and learners. As a result, learners may view feedback as a bureaucratic requirement more than as a learning opportunity, a circumstance that does not nurture learners’ internal motivation. Learners also worry that seeking feedback will not only burden their already overly busy clinician teachers, but may also limit their independence or be mistaken for lack of confidence.10, 11 Consequently, the feedback process may hold few rewards for learners.
So whither self‐assessment? Because of these socio‐cultural influences, attempts to make feedback meaningful often miss the mark. For instance, the self‐assessment component of the intervention reported in this study appears to serve a useful rhetorical purpose, signalling that feedback is something done with, rather than done to, learners. Yet does the usefulness of self‐assessment in these conversations extend beyond the rhetorical and into the educational? We are unsure. For learners to be able to tap into the potential for self‐assessment to inform their learning, they must be willing to be vulnerable enough to put their uncertainties and concerns on full display for their teachers. If learners perceive that their teachers are assessing not only their clinical performance but also their self‐assessment, they may carefully weigh how they present themselves. If, for example, their self‐assessment either over‐ or underestimates their performance, they risk being labelled as lacking in insight. Their self‐assessment itself may become part of the performance, further jeopardising their internal motivation for engaging in an honest feedback conversation.
Does the usefulness of self‐assessment in these conversations extend beyond the rhetorical and into the educational?
Learners are fiercely protective of their professional identities and are quick to discard feedback that does not match their self‐perceptions of their performance. When feedback either stops being meaningful or starts to feel threatening, learners disengage. Given the position at which participants in the present study sat on the motivation spectrum, we suspect that the self‐assessment component also carries risk for becoming a staged performance rather than an honest unveiling of vulnerability. To drive meaningful feedback, as well as learners’ motivation to seek it, we must change the culture to one that embraces vulnerability and inspires honest conversations. Achieving culture change, however, is no easy task.
We must change the culture to one that embraces vulnerability and inspires honest conversations