Giving Effective Feedback
Making a Better Sandwich
Tien Bui, DO
Kristian Sanchack, MD
Activity #1 – Feedback Reflection – 3 minutes
Write down 1-2 words that come to mind when you think of feedback. Share these with the
others at your table.
Be prepared to discuss any common themes that are present.
Activity #2 – Feedback in literature – 8 minutes
Highlight concepts of effective feedback that are important to you.
Be prepared to discuss with the group.
Giving Effective Feedback by W. Fred Miser, M.D.
The feedback we give to students should be for one primary purpose - to keep them on course
so they arrive successfully at their predetermined destination (the attainment of the skills,
attitudes and behaviors that will make them outstanding physicians).
Feedback is not "rocket science." It is an objective description of a student’s performance
intended to guide future performance. Unlike evaluation, which judges performance, feedback is
the process of helping our students assess their performance, identify areas where they are right
on target and provide them with tips on what they can do in the future to improve in areas that
Students will invariably say they do not receive enough feedback from us as teachers. Think
about your own training. Did your teachers let you know what you were doing right, and what
areas needed improvement? Did you receive enough feedback? Chances are your teachers let
you know when you strayed off course, but did they focus on what could be done in the future so
that you would not repeat the error? To be effective, feedback should consist of these
1. Good feedback should be timely. The best feedback occurs on a daily basis, not just at the
end of the rotation. If done frequently, our comments will seem less like an evaluation, and
more like helpful suggestions. Take time after an encounter or procedure to provide
feedback to the students.
2. Feedback is meant to be constructive. It is intended to improve future performance, and
should be given for no other reason. It is not meant to demean or punish the student.
Describe your observations and your own reactions.
3. The best feedback is specific. Use precise language about what specifically they did right or
what they need to do to improve. Students may momentarily feel good about themselves
when you say, "You did a good job." However, they will also wonder what specifically they
did that earned your praise. Instead of saying, "You are clumsy," provide specific feedback
such as, "The patient appeared uncomfortable when you were using the otoscope."
4. Feedback is focused on behavior, preferably ones that can be repeated, and not on the
individual. Focusing on the behavior allows a dispassionate dialogue with the student.
5. Good feedback should be based on personal observations, not on hearsay.
6. Feedback should be verified. Make sure the student understood your feedback, and then
follow up with a plan to monitor and assist the student in those areas that need correcting.
There is an art to giving feedback. If not done properly, or done with the wrong intention, the
student will take your comments as criticism. At the beginning of the rotation ask the students
how often they would like feedback, and develop a plan on providing that feedback to them.
Then, before you provide feedback, take a few moments to choose the words you will use, and
confirm your motivation that you are providing that feedback to improve their performance.
Avoid evaluative language; its use can cause the student to respond defensively.
Feedback should be done as soon as possible, unless emotions will interfere with the session.
Excellent feedback given at an inappropriate time may do more harm than good. Often after a
bad outcome, students are working through their own emotions, and are often quite critical of
their performance. At this time, brief feedback and emotional support are best, followed later by
a more detailed feedback session. Feedback should also be done in private, unless it can be given
in such a manner as to not be embarrassing. An old axiom is to "praise in public" and "critique in
It is often helpful to ask the students to assess their own performance. Often they will be more
harsh about their performance, which then allows you to be more positive in your approach. It is
much easier and more effective for you if the students identify areas for improvement; you can
then help them develop a plan of action as to how they can do things differently in the future.
When assessing performance, focus on what went well, and what can be improved. Gain
consensus with the students; feedback is more effective if you and the students agree on this
assessment. Some educators advocate the P-N-P (positive-negative-positive) sandwich approach
to providing feedback. Begin with a positive statement, then give corrective feedback and
conclude with another positive assessment. However, the positive comments must be genuine, or
you will lose credibility with the student. Remember to focus on the performance and behavior,
not on the person. Also, focus on those behaviors that the student can do something about.
Reminders about shortcomings over which the student has no control only leads to frustration.
When determining a plan of action for improvement, ask the students what they can do.
Again, gain consensus with the students; future performance is more likely to improve if they
agree with the plan. It is helpful to set goals for future performance. "Next time you encounter
this, try this...," then verify that the students understand, and if the opportunity arises, confirm
that they did change their behavior.
In conclusion, Jack Ende has written, "The goal of clinical training is expertise in the care of
patients. Without feedback, mistakes go uncorrected, good performance is not reinforced and
clinical competence is achieved empirically or not at all." (Ende J: Feedback in clinical medical
education. JAMA 250(6):777-81, 1983).
We should provide feedback often to our students, helping them to stay on track so they can
achieve their ultimate goal of being outstanding physicians. It is a skill that can be developed,
and I encourage you to keep this foremost in your mind as you work with the students in your
Activity #3 – Feedback versus Evaluation– 3 minutes
Using an arrow, place the descriptive words under the appropriate heading. Some words may
fall under both headings.
Activity #4 – Cases 3 minutes
In groups of 2, each person pick one scenario. Highlight items from your scenario that you
would use to provide feedback keeping in mind SOME-TLC.
Case #1: (Medical resident scenario)
You observe a resident performing a colposcopic exam, and biopsies. The resident was
excellent in the explanation and consent of the procedure to the patient.
The patient jumps slightly during the placement of the speculum and states, “that’s
uncomfortable!” The resident repositions the speculum slightly and states “ Sometimes it is
going to hurt a little”. The resident follows the appropriate sequence of actions, identifying an
appropriate area to biopsy. As the resident continues with the procedure, the patient
intermittently makes sounds of slight discomfort when the speculum is bumped and particularly
with the biopsy.
When the resident has completed the procedure, the patient asks if she can have any
medication for pain. The resident replies stating, “colposcopy is not that painful, and you should
be fine with over-the-counter Motrin. Even that is not needed for most people.”
The resident concludes by stating he will call the patient with results, and he feels
confident that she has only minor changes, that may not require further intervention.
Case #2: (Non medical scenario)
You are teaching a class via a series of interactive workshops. Most but not all students
are there as an elective course. The curriculum requires reading between sessions. All sessions
require active participation
You note that a Mary is frequently 4-5 min late for each session. She often seems to be
poorly organized upon arrival. She is somewhat reluctant to be involved. Today during a group
session she was texting on her phone. Another student asked her to participate or leave. She
set the phone down, and returned to the activity.
When she does participate she gives insightful answers to the group. She is good at
following specific directions when engaged. However this does not occur every session. You
overhear a student stating, “Mary seems is either completely unaware that she is a drag on our
group, or she just doesn’t care”.
Activity #5 – Giving Feedback – 10 minutes
Using the items you highlighted above, practice giving SOME-TLC using the Ask-Tell / Teach -
Ask-Act model. Switch turns with your partner.
Be prepared to discuss with the group how you about your interaction.