Feedback fundamentals in surgical education: Tips for success

Humans are notoriously poor at assessment. Acknowledging areas for personal improvement can be onerous and humbling, whereas identifying and informing others of their strengths and fallibilities can be daunting and uncomfortable. However, an understanding of one’s weaknesses and limitations is essential for growth.

Formative feedback is defined as information communicated to a learner with the intention of modifying his or her thinking or behavior to improve learning. This process provides the framework by which non-evaluative, supportive, timely, specific, and actionable feedback can result in measurable improvements in the learner’s knowledge, skills, or behaviors. Identified as one of most important influences on learning, feedback alleviates uncertainty and illuminates a pathway to success.^1,2

Formative feedback is especially important for the surgical trainee. For the safety of the patient, positive technical and non-technical behaviors must be reinforced, while negative behaviors need to be modified before the surgeon begins independent practice. Formative feedback contrasts sharply with common, non-specific evaluations such as “good job” or “needs to read more,” which are unlikely to motivate the recipient to improve performance. This article reviews critical concepts in the delivery and receipt of feedback to optimize success in surgical practice.

Feedback and improved performance

Providing feedback to students and trainees is a time-honored tradition in medicine, and in light of the challenges brought on by duty-hour restrictions and limited operative autonomy, this type of assessment has become increasingly recognized and valued.³ Numerous strategies have been developed to ensure timely delivery of feedback, including deliberate practice, debriefing, and coaching.^4-9 While the transferability of other educational strategies, such as surgical simulation, has been well established, less is known about the attributable impact of feedback on operative performance.^10-13

Improvements in time to completion of laparoscopic cholecystectomy, reduction of technical errors, and enhancements in the economy of movement have all been demonstrated by surgical trainees randomized to groups receiving constructive feedback compared with those receiving none.¹⁴ In addition, feedback during and following deliberate practice in virtual reality training simulators has resulted in superior technical performance in porcine laparoscopic cholecystectomy models as well as in the operating room (OR).^4,5,9 A recent randomized-controlled trial evaluating the influence of coaching and feedback on the performance of the jejunojejunostomy during laparoscopic Roux-en-Y gastric bypass revealed that residents who received comprehensive coaching, including performance analysis, debriefing, feedback, and behavior modeling, scored higher on a procedure-specific skill scale and made fewer technical errors than trainees who did not receive coaching.¹⁵

Often, it can be difficult to find the time for structured, meaningful, and comprehensive feedback sessions. Hence, it is imperative that both the surgeon educator and the learner recognize the value of smaller quanta of feedback delivered in less structured or impromptu interactions throughout the course of a day. The following approaches may be useful in facilitating the delivery of effective feedback.

Recognizing feedback: Setting the stage and signposting

To optimize educational value, both educator and learner must recognize when feedback has actually occurred. This has traditionally been challenging for surgeons given the pressures of running an efficient day and the nature of the intraoperative teaching environment. A number of studies have demonstrated that although faculty and residents agree on the importance of feedback, they often have a different perception of how to best convey this information. For instance, research conducted by Hutul and colleagues suggests that faculty think they provide feedback 91 percent to 97 percent of the time, while residents consistently report receiving useful feedback only 17 percent to 30 percent of the time.^2,16 To ameliorate this discrepancy, the educator can adopt two important strategies: setting the stage at the beginning of an interaction, and signposting.

Setting the stage

This strategy requires a more active effort on the part of the educator and is critically important for building a constructive relationship with the learner. Find a place that is relatively private and quiet (including right outside the OR) to facilitate a constructive exchange. Take a moment to establish goals that both educator and learner identify. For example, consider what your expectations are for the learning interaction (short-term, long-term, or both). Perhaps set a mixture of goals—some of which are easily attainable and others that are more challenging. Setting the stage prior to a scenario that may be stressful or technically difficult may also minimize anxiety. Most importantly, take this opportunity to establish an expectation of ongoing feedback and to identify what forms that feedback might take (structured, impromptu, written evaluations, and so on).¹⁷

Signposting

This strategy involves alerting the learner that feedback is about to occur by using the word “feedback.”17 The word makes it clear to both parties that this is a learning opportunity, which should diminish potential discrepancies in perceptions of feedback. While signposting is easy to do in a more structured setting, using this strategy for impromptu feedback that occurs in the OR is more difficult and the lesson is less likely to be retained by the learner. Feedback in the OR is also often disguised as technical tips or disapproving (or approving) speech and/or body language.

Surgeon educators may get acknowledged for, and learners may more easily recognize, these common OR interactions as feedback if retrospective signposting is used. Retrospective signposting refers to the acknowledgment that feedback has occurred after the fact. Retrospective signposting might occur after an exchange between instructor and learner. The educator could state, “I hope that the feedback on your initial approach to the gallbladder was useful.” Or the senior surgeon might say something like, “During the case, I gave you some feedback on the best way to skeletonize the cystic duct. I would like to suggest that for the next laparoscopic cholecystectomy, we establish a new goal based on that feedback.”

Table 1. Do’s and don’ts for effective feedback

Do	Don’t
Discuss shared goals Provide timely feedback Signpost your feedback Give specific examples Provide constructive feedback Make feedback routine Make feedback part of the culture	Give harsh or overly negative feedback Give feedback that is: Overly broad Non-specific Too general Delayed Give unachievable goals

Providing effective feedback: The important components

Many educators struggle with providing useful, honest, and specific feedback. Traditional post-rotation assessments are fraught by the long latency period between the subject of the feedback and end of the rotation. Additionally, they are typically overly broad or generic and are neither actionable nor specific. To be effective, feedback should be timely, concise, actionable, and specific. In one example, residents generally regarded feedback as inadequate, vague, and non-specific, whereas the faculty providing the feedback felt it was useful.¹⁸

Ideally, feedback should be provided shortly after the event, for maximal impact, but it does not necessarily need to be provided during an interaction. For example, in a stressful situation, it may be difficult for the teacher to provide and the learner to incorporate the feedback, so a debriefing session afterward may be more appropriate. Feedback should be specific, referring to precise behaviors or points of knowledge. It should be concise and focus on only one or two points. It should be clear and actionable, and the educator should be able to explain how the feedback can lead to improvement.

Tailoring feedback to the audience

The general strategies highlighted in this article for providing effective feedback are independent of the level of the learner. However, it is important to recognize that medical students, residents, and attending surgeons all have different expectations for delivery and receipt of feedback.

Medical students

A medical student rotating on surgery has specific feedback needs. Students are often assigned concrete tasks that may not require extensive feedback, such as collecting vital signs before rounds, changing dressings, retracting tissue, or holding the laparoscope. These tasks expose the student to different components of surgical care, and it is the student’s understanding of these components that should be assessed. For example, students pre-rounding and recording vitals do not want and should not need feedback on whether they copied the numbers correctly. Instead, their understanding of the importance of the vital signs they recorded can and should be evaluated. Tachycardia in a postoperative patient, for instance, should lead to a brief discussion of the normal range of vital signs and a longer discussion of the differential for postoperative tachycardia.

Residents

Surgical residents are primarily concerned with two main tasks: mastering technical operative skills and patient management. The feedback they receive should focus on those two domains and should be specific to the level of training.¹⁹ Expecting a surgical intern to perform any laparoscopic procedure skin-to-skin with minimal guidance may be possible for only a few select individuals, as most interns have yet to attain the skills and confidence needed to succeed. In contrast, a senior surgical resident at many programs would be expected to perform all aspects of the surgical encounter from consent, positioning, and setup (including the ability to troubleshoot the oft malfunctioning laparoscopic instrumentation), and safely perform the critical aspects of the procedure with minimal coaching.

Attending surgeons

Many medical students and residents shy away from providing feedback to their attending surgeons, but their hesitation may be unwarranted. The surgeon who takes a job at an academic hospital and is involved in resident education does so knowing that medical student and resident education is a vital responsibility.²⁰ Although potentially intimidating, it is appropriate for a resident to approach an attending and provide feedback after an operation. In fact, this dialogue is necessary for all parties to gain the most from an experience. Importantly, “upward feedback,” as it is known, should be used to enhance the educational benefit of the learner.²¹ This type of feedback should be used to reinforce the positive aspects of the interaction and serve to enhance the collegial and educational relationship between the learner and educator. For example, the resident might make the following statement: “I like when you let me decide which stapler to use.” It can also be used to communicate what isn’t working for the learner, with a statement such as, “I don’t understand what you mean when you say….”

Conclusion

Effective formative feedback provides the opportunity for self-assessment and usually ends with a plan for improvement. When delivered consistently and appropriately, feedback can lead to more a productive instructor-trainee dynamic.¹⁷ In surgery, specifically, good instructors are identified as those educators who challenge trainees to think, provide useful feedback for their work, communicate ideas well, and express a positive attitude toward trainees and teaching.²² At the fundamental level, the medical student, the resident, and the attending all share the same goal—to provide the best care for the patient. Well-executed feedback provided at all levels of training and/or practice should be recognized as essential to this most basic mission.

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References

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