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Revista Portuguesa de Medicina Geral e Familiar

versão impressa ISSN 2182-5173

Rev Port Med Geral Fam vol.29 no.5 Lisboa set. 2013

 

EDITORIAL

The power of feedback: the importance of feedback in clinical practice and teaching in family medicine

John Yaphe*

*Associate Professor, Community Health, School of Health Sciences, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence


 

In his essay “Words that are hard to say and hard to hear”, Anderson Spickard says that “feedback is a gift that is not to be ignored but revered and pursued”.1 In this editorial we will explore the nature, role and importance of this gift in the teaching and practice of family medicine.

An old joke tells of a farmer who speaks to his plough-horse after ploughing a particularly difficult field. The farmer says to the horse: “You are a good plough horse but there are some things that you can improve. When you come to the end of the field, you can take shorter turns to make straighter rows. But what I would really like to hear is what you think of your performance as a plough-horse”. To this the horse replied angrily: “I said give me the feed-bag, not the feedback.”

This story illustrates the elements and importance of good feedback as summarized by Beverly Wood.2 Feedback starts with a positive tone to win over the listener from the beginning. It is timely and given as close as possible to the event in question. There is little value in dredging up old memories when recall bias can cloud the picture. Often little can be done to change the consequences of events long past. It must be desired because it is most effective when it falls on willing ears. It should focus on the behaviour and not the personality of the learner so that it leaves room for change. For the same reason it should be as specific as possible. Saying to someone “you are a good horse” (or a good student or a good doctor) provides little in the way of direction for change. Finally, the best feedback comes from quiet self-reflection. Asking the learner how they think they can improve their own performance often leads to the most constructive changes. The suggestions for change then become their ideas.

We use feedback in many ways in the teaching and practice of family medicine. Students are constantly completing questionnaires at the end of courses and clinical rotations during their medical school career. How often do we take to the time to reflect on the content of these forms to see how they can improve our teaching? How can we interpret the numerical values on feedback forms so that they can have practical effects?

One of the best ways to do this is to supplement the written form with a face-to-face feedback session with the learner. Four questions can be particularly helpful. You can start with: “what did you like most about this rotation?” Next, ask: “what did you enjoy but found there was not enough and wanted more?” Third, ask: “what did you enjoy but could you do with less?” Finally, ask for general comments and suggestions. All this creates a positive atmosphere with a clear to commitment to improving the teaching and learning experience. This is similar to the method used in qualitative research.

The same guidelines apply in giving feedback to students, trainees and colleagues. Many of our learners have had negative experiences with feedback during their training. Some might even bear the scars of educational abuse and perpetuate this when they become teachers. Constructive, supportive feedback can help to break this cycle by providing a corrective experience.

There are many ways to do this. When we set clear learning objectives at the beginning of the rotation, and choose appropriate learning methods to go with that, we make the final assessment easier. This can be done with a summative feedback session. We can start with the learner by asking them what they liked and learned, what went well and what they might do differently next time to make their learning even more effective. We can then provide specific, constructive, behavioural observations and suggestions that can help them on their way. Pendelton’s Rules provide a nice summary of this process and are often used in providing feedback to trainees after presenting a video review of a consultation.3 They focus on the positive and allow room for growth.

This can also apply to our encounters with patients. Teaching and therapy are parallel processes, if we adopt a growth model rather than a transmission model. We do not really cure patients. We can however provide the right physical, emotional and social agents under the right conditions to promote healing and growth. In the same way that all learning is self-learning, all healing is self-healing. Our patients can provide us with valuable information on how effective we are at this task and how we can improve. We have only to ask them and listen.

Patient satisfaction surveys are part of the drive to obtain useful patient feedback in clinical practice. The Europep instrument has been used widely here to measure patient satisfaction with primary care.4 A new instrument has recently been proposed to replace this as a performance indicator of excellent practice.5 We need to keep looking for simple accurate tools that can help us improve the quality of our care. Qualitative research methods, as described in a recent editorial here, can provide useful feedback for improving the quality of clinical services.6

In the same way that teaching and practice benefit from good feedback, so too can scientific journals, such as this one. The editors and reviewers of manuscripts constantly provide feedback to authors in the process of peer review. This was also the subject of a recent editorial here.7 We hope that it is constructive and helpful. We are constantly working on providing timely replies, which is difficult to achieve with a volunteer staff of busy clinicians who serve as our editors and reviewers.

Our readers also provide us with valuable feedback in the form of letters to the editor. We enjoy receiving them and reading them and we like publishing them. We believe that true peer review happens out there among our readers. If you like a study and it matches your clinical experience, please tell us that in writing. If you find fault in a paper or have conflicting evidence please tell us that too. That is the way science progresses. If you have important clinical or research findings that merit dissemination, you can send us that as well. You have a better chance of publishing your findings in a brief research letter than as an original article, given the size limitations of this journal and the number of papers we currently have under review.

We have benefitted from your feedback (written and verbal, formal and informal) in our tenure as editors. We thank you for this gift. We look forward to receiving more letters from you and the reports of your research on the applications of feedback in your teaching and clinical practice.

 

REFERENCES

1. Spickard A 3rd. Words hard to say and hard to hear: “May I give you some feedback?” J Gen Int Med 1998 Feb; 13 (2): 142-3.         [ Links ]

2. Wood B. Feedback: A key feature of medical training. Radiology 2000 Apr; 215 (1): 17-9.         [ Links ]

3. Pendleton D, Scofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press, 1984.         [ Links ]

4. Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H, Hjortdahl P, et al. Patients’ priorities with respect to general practice care: an international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP). Fam Pract 1999 Feb; 16 (1):4-11.         [ Links ]

5. Administração Central do Sistema de Saúde. Bilhete de identidade dos indicadores de monitorização dos cuidados de saúde primários. (Sec. 72, Proporção de utilizadores muito satisfeitos. 2013. p. 207-16). Disponível em: http://www.acss.min-saude.pt/Portals/0/R_DOC_BI_01_DETALHADO_2013_01_11.pdf.pdf (acedido em 10/10/2013).         [ Links ]

6. Yaphe J. Qualitative research in primary care in Portugal: long overdue. (editorial). Rev Port Med Geral Fam 2012; 28 Jan-Feb (1): 15-6.

7. Yaphe J. Rethinking peer review: an empty slate (editorial). Rev Port Clin Geral 2011 May-Jun; 27 (3): 259-60.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

The author has no conflict of interest in the publication of this editorial.

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