On Feedback to Enhance Performance

From social media feedback loops that generate marketing algorithms to digital health feedback from smartwatches, feedback mechanisms have become commonplace in our lives. Feedback, similarly, has become increasingly essential in modern medicine. For example, in graduate medical education, there has been a paradigm shift from traditional time-based advancement of residents to a competency-based model.1,2 Previously, the amount of time spent in an apprenticeship format was used as a marker for a resident’s skill level. The focus has now shifted to continuous formative feedback to promote optimal performance and support learning assessments. Patient feedback is also now being leveraged by the government and individual health care institutions to improve care and patient experience.3,4 It is important to have a solid grasp of different theoretical frameworks for feedback, along with the skills to effectively provide and accept it. Lacking this foundational knowledge diminishes the quality of feedback and hinders progress. One study found that more than one-third of common feedback delivery methods actually led to a decline in performance.5,6 Despite the value of effective feedback, medical education often falls short in providing substantive training or a theoretical foundation for it.7 Not surprisingly, more than 25% of residents reported being dissatisfied with feedback they receive.5 In this editorial, we delve into the intricacies of feedback by exploring its theoretical underpinnings, establishing a framework for effective feedback delivery, and offering insights on receiving feedback adeptly for personal and professional growth. WHAT IS FEEDBACK? The modern concept of feedback as a tool for improvement was formalized and systematically applied by rocket engineers in the 1940s. Feedback is defined in the Oxford English Dictionary as “the modification, adjustment, or control of a process or system.”8 Massachusetts Institute of Technology professor Norbert Wiener first recognized the broader applicability of feedback.9 In introducing this concept to the humanities, Wiener stated that using results simply “for criticism of the system and its regulation” only provided “simple feedback of the control engineer.”10 However, if feedback is able “to change the general method and pattern of performance, we have a process which may very well be called learning.”10 Feedback, for purposes of this editorial, is best understood within the context of the cycle of learning. The process of learning begins with establishing educational objectives followed by a period of instruction, studying, or practice, and often concluded with an assessment. Feedback has historically been incorporated into 2 aspects of this learning continuum: as a formative assessment meant to help the learner improve and as a summative assessment used at the end of a learning cycle to make final judgments about the learner’s success.5 Summative assessments are important to ensure those licensed to practice medicine meet accepted standards. However, for the purposes of this editorial, we focus on formative feedback because it is more commonly provided and has broader applicability.9 HOW DO YOU GIVE EFFECTIVE FEEDBACK? Providing feedback commonly engenders anxiety for both the giver and receiver. This anxiety can lead the feedback giver to deliver indirect and unclear assessments that obscure the intended message.9 Similarly, anxious recipients may perceive constructive feedback as judgment and respond with defensiveness and frustration. To circumvent these challenges, it is crucial for the feedback giver to frame the exchange as an objective, constructive dialogue aimed at fostering growth. Giving effective feedback includes 3 key components: (1) an ideal environment, (2) collecting relevant feedback, and (3) appropriately structuring the conversation. Establishing an Ideal Environment for Feedback An environment must be cultivated in which the feedback giver is encouraged to offer clear, direct feedback, and recipients are empowered to view themselves as active participants in their development. Creating this culture is difficult on an individual level; it is more effectively achieved within an organizational framework. In the organizational context, an ideal environment is cultivated by nurturing a growth mindset, establishing routine feedback, and equipping staff with skills necessary for effective feedback. Nurturing a Growth Mindset Establishing a growth mindset within an organization requires a holistic approach that affects hiring practices, methods of evaluating performance, and leadership. In the hiring process, a “culture of genius,” which emphasizes inherent intelligence and previous accomplishments, should be contrasted with a “culture of development.”11 This latter approach values prospective employees who actively seek to learn and expand their skill sets. Employees hired within a culture of development framework are more likely to be receptive to feedback and appreciate how best to leverage the feedback they receive. Microsoft CEO Satya Nadella encapsulated this cultural ethos by stating that “the ‘learn-it-all’ outperforms the ‘know-it-all.’”12 This perspective emphasizes the importance of curiosity, adaptability, and continuous learning in driving personal and organizational success. By prioritizing growth over perfection, organizations cultivate innovation and resilience. Similarly, when evaluating performance, focusing on process and effort in contrast to intelligence and past success motivates trainees to tackle challenges that uncover opportunities for enhancement. In the context of clinical education, a traditional approach may include surgeons assessing trainees on the basis of their ability to quickly master technical skills. However, shifting focus toward the process and effort, where trainees are encouraged to articulate the difficulties they encountered, strategies they used to overcome these challenges, and lessons learned from the experience, is more consistent with a growth mindset. Trainees who overcome flawed hand–eye coordination that limited their initial progress, for example, are not seen as less capable but recognized for their effort to improve through practice and proactively seeking feedback. This approach supports a culture where trainees are motivated to engage with demanding tasks, viewing them as opportunities for growth rather than an experience for which they will be judged. The mindset of leadership is also pivotal in cultivating a growth-oriented culture. Leaders who perceive themselves as talent judges rather than mentors dedicated to nurturing improvement misunderstand the essence of their role. Such leaders lean toward a carrot-and-stick approach, driven by a belief in fixed abilities.13 In contrast, growth-minded leaders adopt a coaching stance, committed to aiding their team’s continuous development. For instance, in a surgical setting, effective leaders shift focus from outcome metrics and judgment to active mentorship. Effective leaders will frame debrief sessions not as a critique of failure but as a platform for learning. Establishing Expectations of Routine Feedback An organization succeeds in a culture where routine feedback is anticipated and encouraged across all levels. Unlike learning environments such as sports and music, where negative feedback is an expected and essential part of growth, medicine has yet to fully embrace this practice.14 Feedback in medical training often remains superficial, providing insufficient guidance to make meaningful improvements.15 Fostering a culture in which all members view themselves and each other as learners, and where feedback is embraced as a powerful tool for growth, establishes a growth mindset in which routine feedback becomes normal and expected.16 Instituting a formalized feedback program is a proactive step to instill this culture of routinized feedback. Such programs may include scheduled short- and long-term feedback sessions and multisource feedback (MSF), such as 360-degree reviews, which encourage input not only from attendings but also from peers and trainees.17,18 MSF reinforces the idea that feedback is a normal shared responsibility rather than a strictly hierarchical process. Incorporating tools like “frame-of-reference” sessions, which standardize evaluators’ understanding of performance criteria and expectations, helps align expectations across the organization, ensuring consistency and fairness in feedback delivery.19 Providing Staff Development Sessions Staff development sessions provide low-stress, efficient opportunities to equip staff with skills necessary for effective feedback.20 These sessions can take a variety of formats. University of Michigan Plastic Surgery dedicated a journal club session to feedback in November of 2021. Faculty and residents discussed overcoming barriers to feedback, receiving frank feedback, and establishing a system to receive routine, meaningful feedback. Other formats may include interactive workshops, role-playing exercises, or peer-led discussions on effective feedback strategies. Physicians should ultimately view feedback as a skill that can be developed and honed through deliberate practice.7 Collecting Relevant and Specific Feedback In the 1970s, Dr. George Engel, one of the pioneers of modern medical education, lamented the lack of direct observation in medical training: “If musicians learned to play their instruments as physicians learn to interview patients... the instructor, of course, would not be present to observe or listen to the student’s efforts, but would be satisfied with the student’s subsequent verbal report of what came out of the instrument.”21 Engel’s critique underscored the need for experiential learning and direct feedback in clinical practice. Nevertheless, studies consistently demonstrate that direct observation continues to remain insufficiently used in medical training.22,23 This is particularly relevant for clinical skills, such as surgical techniques, which rely heavily on the integration of multiple cognitive and psychomotor behaviors. These skills are far easier to teach and refine through direct observation than through verbal explanation alone.22,24 However, relying solely on direct observation for feedback is insufficient. Certain soft skills, such as interpersonal dynamics and leadership, cannot be fully captured through observation alone; they often unfold in subtle, context-dependent ways, requiring input from multiple perspectives. Incorporating MSF, such as 360-degree reviews, provides a more holistic understanding of performance, uncovering qualities that might otherwise go unnoticed. For example, Jack Welch, former CEO of General Electric, emphasized the importance of shared values in leadership.25 In his values matrix (Fig. 1),26 he described type 4 leaders—those who deliver results without aligning with core values—as “autocrats” or “tyrants” who harm teams and long-term organizational health, and often go unnoticed by management without diverse perspectives.26 More than 90% of Fortune 1000 companies adopt some form of MSF.27Fig. 1.: GE leadership values matrix. Adapted from London M, Beatty RW. 360-degree feedback as a competitive advantage. Human Resource Management 1993;32:353–372, with permission from John Wiley some of the most common are described in Figure 2.5,36–40 Many individuals who commonly provide feedback already implement one or more of these methods intuitively, and feedback sessions often combine elements from multiple approaches. However, understanding these models and their respective benefits and drawbacks provides feedback givers a broader toolkit, and helps structure future conversations more thoughtfully and effectively.Fig. 2.: Common feedback formats.Regardless of the feedback model used, concluding the session with a jointly developed action plan enhances its effectiveness. Inviting the recipient to propose an action plan, which the giver can then endorse or refine, helps foster the recipient’s ability to self-direct improvement.41,42 This approach frames the feedback session as a collaborative discussion for growth, rather than a prescriptive list of remediation steps that could be perceived as admonishment.20 Content of Feedback Sessions The content of feedback should adhere to several key principles to ensure it is constructive and facilitates growth. First, feedback that is nonjudgmental and descriptive, focusing on specific observations rather than personal evaluations or generalized judgments, helps minimize defensiveness and ensures that feedback is perceived as actionable rather than critical.9,20,43 Another principle is prioritizing remediable behaviors. Feedback that focuses on areas where change is possible is more effective, whereas emphasizing irreparable deficits can undermine recipients’ motivation and suggest a misalignment between their goals and capabilities. If deficits are substantial and not easily resolved, feedback can guide recipients toward reassessing their broader goals rather than emphasizing how to achieve an unfeasible outcome.9 Specificity and clarity are also essential; feedback that includes clear examples has been consistently shown to be more impactful, as it provides actionable insights that the recipient can readily apply.7,42 For instance, praising specific actions (eg, “your analysis was thorough and well-organized”) is far more effective than vague compliments (eg, “good job”) or personal affirmations (eg, “you’re outstanding”).5,9,20 Effective feedback prioritizes the recipient’s actions rather than the giver’s interpretations of intent.35 This ensures that the discussion remains centered on observable behaviors and their impact, rather than speculating about motives. By adhering to these principles—nonjudgmental delivery; a focus on remediable behaviors, specificity, and clarity; and prioritization of actions rather than intent—feedback sessions foster meaningful improvement aligning with the recipient’s HOW DO YOU FEEDBACK? feedback is not a it requires and a to Feedback recipients responsibility to foster an environment to feedback. This requires actively before and the emotional that feedback often This recipients to process feedback thoughtfully and provide a constructive or the feedback in limited or feedback that ultimately the recipient from fully the benefits of feedback. 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