unfulfilled promise, untapped potential: feedback at the crossroads
TRANSCRIPT
2014, 36: 692–697
Unfulfilled promise, untapped potential:Feedback at the crossroads
CHRISTOPHER J. WATLING
The University of Western Ontario, Canada
Abstract
Feedback should be a key support for optimizing on-the-job learning in clinical medicine. Often, however, feedback fails to live up
to its potential to productively direct and shape learning. In this article, two key influences on how and why feedback becomes
meaningful are examined: the individual learner’s perception of and response to feedback and the learning culture within which
feedback is exchanged. Feedback must compete for learners’ attention with a range of other learning cues that are available in
clinical settings and must survive a learner’s judgment of its credibility in order to become influential. These judgments, in turn,
occur within a specific context—a distinct learning culture—that both shapes learners’ definitions of credibility and facilitates or
constrains the exchange of good feedback. By highlighting these important blind spots in the process by which feedback becomes
meaningful, concrete and necessary steps toward a robust feedback culture within medical education are revealed.
Introduction
Much of the clinical learning that occurs in medical training is
situated in the workplace, where opportunities to participate in
real clinical activities are central to learners’ development
(Teunissen et al. 2007; Watling et al. 2012). Medical learners
require more than mere access to clinical experiences,
however; they also require deliberate support for the value
of experiential learning to be optimized (Yardley et al. 2012).
Feedback is a key element of that support. The place of
feedback as an essential and indispensable element of
effective clinical learning has been strongly endorsed by
educators and learners alike (Ende 1983; Hesketh & Laidlaw
2002; Schultz et al. 2004; Cantillon & Sargeant 2008). Why,
then, is feedback not consistently perceived as useful and
effective? The reality is that feedback is a complex tool for
influencing learning. If feedback is to fulfill its educational
promise, we must understand both how it comes to be
meaningful and why it might fall short.
Promises made
Feedback is more than just information; rather, it is information
whose explicit purpose is to promote improvement in learner
performance (Sadler 1989; Archer 2010). Feedback promises
to provide motivation and direction for learning, guiding and
shaping how learners make sense of the experiences the
workplace provides and offering them a path forward. Without
feedback, Ende (1983) warned, ‘‘mistakes go uncorrected,
good performance is not reinforced, and clinical competence
is achieved empirically, or not at all’’ (p. 778). A chronic failure
to provide medical learners with effective feedback may lead
them to rely on self-assessment when judging the adequacy
and quality of their developing clinical skills, excluding
necessary information from external sources (Ende 1983).
But self-assessment as a personally generated judgment of
performance effectiveness has frequently been demonstrated
to be inadequate (Gordon 1991; Davis et al. 2006). If we are to
move toward a more sophisticated notion of self-assessment as
deliberately informed by feedback from trusted external
sources, then meaningful feedback that delivers on its
promises must be routinely available to learners (Eva &
Regehr 2005).
Promises kept?
The feedback promise sounds so simple: provide learners with
information about their performance, highlighting both its
strengths and its shortcomings and they will move forward
with enlightenment and a clear path for their development.
Educators and learners alike recognize, however, that the
reality of feedback is far from straightforward, and that the
experience of giving and receiving feedback is often far less
Practice points
� The challenges to ensuring that feedback is meaning-
ful lie both with the individuals involved and with the
learning culture that contains and supports feedback.
� Feedback must compete for learners’ attention with
other learning cues; its credibility determines whether
learners choose to engage with it.
� Medicine’s current learning culture is not a robust
feedback culture.
Correspondence: Dr. Christopher J. Watling, Associate Dean, Postgraduate Medical Education, Schulich School of Medicine and Dentistry, Medical
Sciences Building Room M103, Western University, London, Ontario N6A 5C1, Canada. Tel: 519-661-2019; Fax: 519-850-2492; E-mail:
692 ISSN 0142-159X print/ISSN 1466-187X online/14/80692–697 � 2014 Informa UK Ltd.
DOI: 10.3109/0142159X.2014.889812
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satisfying and productive than would be hoped. In a large
meta-analysis of feedback interventions in a wide variety of
settings, ranging from test performance to reaction time to
adherence to regulations, Kluger and DeNisi (1996) demon-
strated that although feedback had a beneficial impact on
performance overall, its effect size was modest. Furthermore,
in a sobering one-third of studies they considered, feedback
actually diminished performance (Kluger & DeNisi 1996).
Other researchers have found similar variability in the impact
of feedback on learning. In a meta-analysis of the effect of
feedback in the setting of test-like events, Bangert-Drowns
et al. (1991) found a modestly beneficial effect of feedback on
achievement overall; but in 18 of 58 studies they considered,
the effect of feedback on performance was detrimental.
Hattie’s (1999) synthesis of multiple studies of influences on
student achievement painted a somewhat more encouraging
picture: feedback emerged as one of the strongest influences
on student achievement, seemingly affirming its power to
shape learning. Even in this study, however, there was
considerable variability in the reported effect sizes across the
hundreds of studies he considered, suggesting that some forms
of feedback are more effective than others (Hattie & Timperley
2007). Despite their different contexts, these studies provide
ample warning that we cannot approach the use of feedback
in any educational setting with the presumption that it will be
effective in promoting learning and performance improve-
ment. These studies do, however, suggest that feedback is
sometimes effective for learning. Understanding under what
conditions feedback improves performance thus becomes a
critical challenge for medical educators.
Revealing the blind spots
Historically, the literature on feedback has tended to focus on
its delivery, providing advice to supervisors on how to create
and provide effective feedback (Cantillon & Sargeant 2008;
Thomas & Arnold 2011; Ramani & Krackov 2012; Schartel
2012). Although such advice is valuable, this focus on
feedback delivery is too narrow to allow a sufficient under-
standing of the process by which feedback acquires meaning
for learners. The reality is that feedback is a complex exchange
of information that involves individuals interacting within a
specific setting and culture. The challenges to ensuring that
feedback is meaningful lie not only with those charged with
delivering feedback but also with the individual learners who
must respond to feedback and with the learning culture that
contains and supports feedback. In our tendency to margin-
alize these individual and cultural influences, we have allowed
dangerous blind spots to afflict our perspective on feedback.
Making these blind spots visible can provide both a reality
check and a way forward.
Reality check: Learners havechoices
Learners approach feedback with a highly individual sense of
motivation and engagement. Their life experiences impact
their orientation toward feedback, their preferences around
feedback styles and their emotional responses to the feedback
they receive (Watling et al. 2013a). Individual learners make
choices about whether feedback merits their attention and
whether to engage in the challenging process of reflecting on,
integrating and acting on feedback’s messages (Watling et al.
2012). For feedback to serve as a meaningful promoter of
workplace learning, we must understand how and on what
basis these individual choices are being made.
In a series of studies, we have explored the experiences
physicians perceive as influential in their learning, and our
findings provide an important reality check on the role of
feedback, placing it into its proper perspective. In clinical
learning, feedback appears to be but one of a range of
learning cues—pieces of information about learner perform-
ance—that might influence learners (Watling et al. 2012).
Besides feedback, these learning cues include patient and
family responses, clinical outcomes, comparisons with peers
and colleagues and role models, who provide aspirational
examples of performance for learners to emulate. As learners
sort through learning cues, they attend to and act upon those
that they deem credible and may discard those that lack
credibility. Feedback from teachers must therefore compete
with other learning cues and must survive a learner’s credibil-
ity judgment in order to become influential (Watling et al.
2012). What are the constituents of credible feedback?
Feedback perceived as credible tends to be timely, specific,
constructive and actionable. In addition, the feedback is more
meaningful when its source is considered credible and when
its messages align with the learners’ own personal and
professional values (Watling et al. 2012).
Reality check: Culture matters
Although learners’ choices about feedback appear to be
guided by their perceptions of and judgments about its
credibility, these credibility judgments are not made in a
vacuum, independent of the context in which they occur.
As Swanwick (2005) has argued, a purely cognitivist approach
that treats the mind as functioning independently of its social
context is inadequate for a full understanding of learning. To
better appreciate the place of feedback in learning, it may be
instructive to consider the problem of feedback through a
sociocultural lens. In contrast to cognitivist approaches to
learning that focus on the learner as an individual, sociocul-
tural theories of learning share the view that learning must be
situated within specific contexts and cultures to be understood
(Brown et al. 1989; Durning & Artino 2011; Mann 2011).
Exploring feedback from a sociocultural perspective means
considering how the values and pedagogical practices of a
profession—its learning culture—shape the experiences of
giving and receiving feedback. In our own explorations of the
influence of learning culture on feedback, we have identified
two key points of impact. First, learning cultures direct how the
very notion of credibility is defined for learners. Credibility,
which so impacts whether learners attend to, reflect upon and
integrate feedback, takes different forms in different learning
cultures (Watling et al. 2013c). In medicine’s learning culture,
for example, a teacher’s credibility as a source of feedback
Feedback at the crossroads
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appears to be grounded primarily in their work performance;
learners look to the strongest clinicians as the most credible
sources of feedback (Watling et al. 2013b). Although this
finding may seem intuitive to those enmeshed in the medical
learning culture, our work comparing medicine’s learning
culture with that of other fields such as music, sports and
teacher training highlights that cultures have distinct ways of
defining credibility. In the learning cultures of music and
sports, for example, the credibility of teachers and coaches is
firmly rooted in their instructional abilities, rather than in their
personal performance abilities; learners in these fields gravitate
to those teachers whose capacity to coax ever-better perform-
ance from their students is greatest (Watling et al. 2013a,b).
Second, learning cultures create conditions that may
facilitate, or inhibit, the occurrence of feedback possessing
the fundamental features that give it value for learners:
specificity, timeliness, actionability and even credibility itself.
Direct observation of learner performance, for example, while
ubiquitous in the learning culture of music, is often conspicu-
ously absent in the learning culture of medicine, where
supervisors and learners typically work in parallel. As a result,
medicine’s learning culture tends to compromise the efforts of
its teachers to provide feedback informed by direct observa-
tion; the credibility of feedback is thus culturally undermined
(Watling et al. 2013b,c). Medicine’s learning culture also tends
to inhibit the development of longitudinal teacher–learner
relationships through its tendency to move learners from one
clinical setting to the next, often with little supervisory
continuity, in contrast to ‘‘coaching’’ cultures such as music
and sports, where teacher–learner relationships may span
years. Meaningful feedback that challenges the learner to
reflect and improve tends to thrive in the setting of strong,
trusting relationships, which some learning cultures support
better than others (Watling et al. 2013a).
An integrated view
Feedback thus involves individuals interacting within a specific
context or learning culture. This notion of integrating the
individual and the sociocultural influences on learning has
figured prominently in theorizing around workplace learning
(Billett 2002; Sheehan et al. 2005; Dornan et al. 2007). Eraut
(2007), in his influential writing on learning in the workplace,
treats individual and sociocultural theories of learning as
‘‘complementary rather than competing’’ (p. 405), drawing on
both perspectives to achieve a fuller understanding of how
individuals learn in workplace settings. Similarly, Billett (2008)
argues that the relationship between the individual and the
social contributions must be central to theories of learning;
learning reflects an interaction between how the workplace
affords opportunities for participation and how the individual
learner chooses to participate.
Just as the workplace affords opportunities for learners to
participate in authentic activities, so too does a learning culture
afford opportunities for meaningful feedback to be exchanged.
Learners cannot be expected to exercise their individual
choice to engage with feedback if the culture in which
they are learning does not make good feedback possible.
But the influence of culture extends further. Even when
feedback is available and learners can exercise the choice to
engage or not, that choice is shaped not only by the learner’s
individual values but also by the values of the culture in which
he or she is learning. Learners’ judgments about the credibility
of their teachers and the value of their feedback are therefore
not as individually generated as they might appear. Rather,
such judgments are rooted in the learning culture that contains
them and shaped by its values and ideology. Feedback is a
product, inescapably, of learning culture, which not only
makes it possible but also shapes how individual learners
interpret and use it.
A wake-up call
Medicine has engaged in significant and ongoing efforts to
ensure that effective feedback is part of its education
programs. Policies have been enacted in the form of accredit-
ation standards that require the regular provision of feedback
(GMC 2009; ACGME 2013; LCME 2013; RCPSC 2013).
Considerable attention has been paid to the structural aspects
of feedback such as content and style of delivery, leading to
articles and workshops aimed at educating feedback providers
about how to construct and deploy feedback effectively
(Cantillon & Sargeant 2008; Thomas & Arnold 2011; Ramani
& Krackov 2012; Schartel 2012). Less attention has been
devoted to learners’ perceptions of and responses to feedback
or the formal and informal processes that support it, although a
growing body of literature has been fruitfully exploring this
area (Bing-You & Patterson 1997; Sargeant et al. 2005; Watling
et al. 2008). And very little attention has been devoted to a
critical examination of medicine’s learning culture and how it
might enable or constrain the exchange of meaningful
feedback. Yet these previously marginalized elements of the
process by which feedback achieves impact must not be
ignored. Careful attention to the key elements of learner
perceptions and learning culture, in fact, can provide concrete
guidance for improving medicine’s current status quo.
Medicine’s on-the-job learning culture creates barriers that
may foil the efforts of even the most well-intentioned and well-
informed of educators to provide meaningful feedback. These
cultural barriers must be addressed urgently if feedback is to
live up to its potential as an important guide to learning. When
we insist that teachers provide feedback on a full range of
competencies every time they fill out an evaluation form, we
force our teachers to create feedback that is neither well-
informed nor credible. We should not underestimate the
danger of the routine provision of poorly informed feedback;
the practice diminishes learner trust in both the assessor and
the process, so that nuggets of truly well-informed and
important feedback may go unnoticed by learners, discarded
with a mountain of meaningless platitudes. We should
encourage teachers to do what is necessary to construct
meaningful feedback, such as deliberately observing learners
in action, but should allow them to limit their feedback to the
areas on which they are well informed (Crossley & Jolly 2012).
Despite the clear importance of observation to feedback’s
credibility, medicine’s learning culture does not foster
C. J. Watling
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observation as a routine practice in many settings. Admittedly,
there are pockets of medical training where observation is the
norm, such as surgical training in the operating room or
observed interviewing in psychiatry training, but much of
clinical learning takes place in settings where the teachers and
learners engage simultaneously and in parallel in the work of
patient care. Clinical scheduling, patient care expectations and
limited compensation for clinical teachers may all conspire
against teachers being able to make the time commitment that
would be required for direct observation to be routinely
employed.
Medicine’s learning culture also compromises the
all-important relational aspect of feedback in two ways. First,
medical learning is typically fragmented. Learners move from
one learning setting to another, as often as every few weeks
throughout a typical program of training. Even within each
learning experience or assignment, the teachers or supervisors
typically change regularly; over the course of a single, four-
week learning experience, a learner may be assigned to four or
more supervisors. This arrangement is particularly striking
when held up against the years- or sometimes decades-long
relationships that develop between musicians or athletes and
their teachers or coaches (Watling et al. 2013a,b). The
consequence is that medical learners struggle to identify
teachers whom they trust implicitly, and teachers, in turn,
cannot fulfill their potential, since they are not afforded
opportunities to know learners well enough to be able to offer
feedback that goes beyond the superficial. Evidence is
beginning to emerge that when medical training is reorganized
to foster the development of extended teacher–learner rela-
tionships, such as in the setting of longitudinal integrated
clerkships, the quality and impact of feedback is strengthened
(Bates et al. 2013). Second, medicine routinely places its
teachers in the conflicted position of serving simultaneously as
feedback-providers and assessors. The need for meaningful
formative feedback is perhaps never more pressing than when
there are serious performance problems identified; but when
such feedback is provided by the same individual who must
make high stakes pass-or-fail decisions, the teacher–learner
relationship is on a shaky ground (Kogan et al. 2012). Fields
such as sports and music have largely divorced coaching from
assessing. Medicine must give serious consideration to doing
the same. The payoff may be substantial.
Changing course
Clearly, culture change is necessary if feedback is to assume a
more prominent role in meaningfully directing learning in
medicine. The commitment that would be required within
medical education to enact such change is substantial. The
scope of this call for culture change raises an important
question. Is the potential benefit to be gained from an
enhanced role for feedback worth the investment that would
be required? With available studies suggesting that the
beneficial effects of feedback on performance are
modest rather than dramatic, the question is not moot
(Bangert-Drowns et al. 1991; Kluger & DeNisi 1996).
There are, in fact, strong arguments against investing
substantially in further efforts to improve feedback. Rising
healthcare costs and global economic challenges make our
times difficult ones in which to find new funds for medical
education. We are being asked to do more with less, and we
cannot afford to enact large-scale new initiatives that promise
marginal success at best. The vast majority of medical learners
develop into competent doctors, and in an increasingly
outcomes-oriented environment, we must ask not only
whether learners would benefit from investments in improving
feedback but also whether society would benefit. If the gain in
terms of the ability to graduate doctors to provide excellent,
compassionate and safe care is incremental at best and non-
existent at worst, the investment is difficult to justify.
It is my view, however, that the investment is worthwhile.
Medical education around the globe is embracing compe-
tency-based models, which emphasize outcomes over process
(Frank et al. 2010; Iobst et al. 2010). In such models,
meaningful assessment of learner performance, both formative
and summative, assumes paramount importance, not only for
learners but also for the public they will serve (Holmboe et al.
2010). Duty hours restrictions threaten to limit the amount of
time learners have available to acquire the skills that they
need, while at the same time, funders of medical education are
unlikely to be interested in strategies that lengthen already
costly periods of training. Learning must either become more
efficient or educators must shift the conceptualization of
training to firmly embed the learning and acquisition of new
skills as an ongoing process that extends well into practice.
Either approach will require a system of guiding learners
toward their goals, and feedback done well offers the potential
to drive this system.
The investment in improving feedback must be strategic,
however. Continued investment in the inadequate approaches
of the past would be indefensible. Increasing the intensity of
training of faculty members in feedback delivery without
addressing the system and cultural challenges that comprom-
ise their ability to put these skills into action will be money
wasted. Training learners to expect feedback, to seek it out,
and to respond more openly and reflectively cannot improve
feedback’s impact unless there is a simultaneous and con-
certed effort to modify the learning culture so that good
feedback is routinely available.
Conclusion: Feedback at thecrossroads
Feedback sits at the crossroads of the individual and the
sociocultural. An adequate understanding of feedback in
medical education requires an appreciation of the influences
of both the learner who receives and processes feedback and
the learning culture within which the exchange of feedback
occurs. Learners are individuals, and each learner will hear,
process and integrate feedback in their own time and in their
own way, sometimes to the frustration of those who must
develop strategies for providing feedback. Learners are crea-
tures of their environment, however. Their responses to
feedback are not entirely of their own making but are indelibly
Feedback at the crossroads
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shaped by the context and culture in which their learning takes
place. For medicine to improve feedback’s impact, it will not
be sufficient to try to influence its learners as individuals.
Medicine must position itself as a feedback culture, which will
require a commitment to significant cultural change. We
cannot afford to fail.
Notes on contributor
CHRISTOPHER WATLING, MD, MMEd, PhD, FRCP(C), is a Neurologist and
Medical Education Researcher in London, Canada. He is an Associate Dean
for Postgraduate Medical Education, Associate Professor in the
Departments of Clinical Neurological Sciences and Oncology and
Scientist at the Centre for Education Research and Innovation, Schulich
School of Medicine and Dentistry, Western University, Canada.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article.
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