Feedback for Learning (FfL)

We still haven’t mastered feedback to drive learning. In the medical world, feedback is seen as a commodity rather than a learning process. This needs to change.

A friend and colleague of mine says that feedback is the oxygen to the soul and that we shouldn’t make people gasp for it.

How true it is that many of us out there are wheezing for some guidance as to how we are doing? We work too often in the dark with little idea of how well we are doing or what we are getting away with that could be better.

“Feedback is the corner stone of effective clinical teaching.” (Cantillon & Sargeant 2008)

This kind of statement is rife in medical education and whilst it is not untrue, it gives little away about what feedback is, how we should approach it, who is best placed to engage in it and when that should happen.

A recent article in Medical Education (Archer, Jan 2010) says that, “Only feedback seen along a learning continuum within a culture of feedback is likely to be effective.” Whilst I agree with this statement most emphatically, I am not sure the article goes far enough in its portrayal of feedback for learning. (FfL)

We have moved over the last decade away from assessment being for the stakeholders only (summative assessment) to a position of using formative assessment to diagnose learning need and to instigate actions to develop and train. (WBAs exemplify this.) What we haven’t quite achieved is the recognition that feedback is not an outcome but is, if it is to facilitate reflection and development, a process. We may talk about the feedback process but most often the result of that process is what is seen to be most important. We still refer to a “critique” of a performance, piece of work or discussion, where the feedback becomes a commodity to be recorded by the trainee. Whilst this outcome based view of feedback persists, it will never fully work as a training and learning tool.

For effective feedback to work in terms of developing knowledge and understanding, attitudes and perspectives and behaviours and actions, it needs to be seen as a process, not an outcome.

This is not a new idea. In 1983 Schon said: “To achieve effective feedback, the health professions must nurture recipient reflection-in-action.” More than 25 years later this is still not happening.

Archer begins to address this but fails to go beyond the outcomes model. He draws a distinction between feedback as directive or facilitative in nature, explaining that “directive feedback informs the learner of what requires correction. Facilitative feedback involves the provision of comments and suggestions to facilitate recipients in their own revision.” In most cases of facilitative feedback the recipient will still focus on the facilitator’s suggestions and comments as the outcomes that must be achieved.

In directive feedback the educator generally tells the trainee how they have done. The trainee then has to understand what has been said, deal with the emotional response that may invoke in him or her and then accept or reject the comment. Acceptance and rejection often have more to do with the emotional response than with the accuracy and relevance of the comments made. In this way what is intended by the educator can often be greatly misinterpreted by the trainee.

Similarly in facilitative feedback, the comments and suggestions, albeit perhaps more acceptably and sympathetically offered, are still dealt with in the same way by the recipient, and may also be interpreted very differently.

Archer claimed that we need to “build on self monitoring informed by external feedback.” I would go further and say that as trainees progress, we need to build on self monitoring within a process of reflective conversations using open questions to guide and develop. Archer says that “the ability to shape capability through self monitoring with self directed assessment seeking requires an individual to accept the feedback provided. “ But if the feedback process is a process where the recipient has to do all the thinking, and the facilitator merely asks appropriate relevant open questions, then there is no feedback to be accepted, except the recipient’s own.

Feedback for Learning (FfL)

What is required is a third form of feedback during which the educator or facilitator does no “telling” whatsoever. Instead the focus is entirely on the trainee, and the trainee does all of the work. Feedback is facilitated with a series of open questions. As a result the learners have to think evaluatively about their experiences. They provide information regarding what they have done or not done, to which they may still have an emotional reaction, but which cannot be immediately rejected as it is they who have stimulated it. To any emotional or difficult reaction the facilitator responds supportively and with questions concerning further actions. In this way the facilitator of the feedback is seen as a helper and supporter of learning, not a critic. The role of the educator is then to move the learner forward to consider ways to address, amend or develop practice for the future.

Archer recommends that feedback is done by trained facilitators and discusses a useful model for scaffolding feedback:

1. Motivate the learner
2. Deconstruct the task
3. Provide direction
4. Identify gaps between actual and ideal performance
5. Reduce risk
6. Define goals

This framework is helpful but still focuses on the facilitator of the feedback as the one who drives the process.

If we return to the model of feedback using open questions only (FfL), we can add to Archer’s scaffolding model with some suggested open questions to elicit learning reflection and thus learning driven feedback.

1. Motivate the learner
• What would you like to get from this review session?
• How do you see this review contributing to your practice?

2. Deconstruct the task
Tell me:
• What happened/what you did
• How you felt/what you assumed/what you believed would happen
• What you think about this experience/have you had this happen before?

3. Identify gaps between actual and ideal performance
• Describe the differences between what you did here and what you would like to do in -x- time?

4. Provide direction & reduce risk
What next steps can you set yourself for this?
How will you do that? Who may you need to help you?

5. Define goals

• Jot down the goals you have set yourself here, along with the time scales, who is involved, where and when you will achieve them and how you propose to review and monitor them.

Previously trainers have been reluctant to use only open questions as they say that the feedback then relies on the honesty and perception and insight of the trainee to identify where they went wrong. It is indeed true that if the trainee is unconsciously incompetent they will not be able to identify errors and ways to develop. However, the skill in using open questions means that the facilitator can enable the trainee to identify that unknown area through questioning and elicitation. This is a skill which is not endemic to all trainers. Therefore the skill must be developed in trainers as well as in trainees.

FfL as professional reflection in action

Feedback is the pre cursor to professional reflection in action. As children we are disciplined so that as adults we develop self discipline. Junior doctors – or anyone starting off in a profession, need to develop professional reflection on and in action in order to function as independent practitioners after some time. If feedback continues to be a commodity that is bestowed from on high, the dependence of trainee upon trainers will never diminish. As educators our role is not just to train, pass on wisdom, transmit knowledge and skills, but to develop the trainee to become critical thinker, reflective practitioner and measured decision maker.

As a consultant surgeon I worked with this week said to me, “I want to teach them to think for themselves.” We can only do this if the feedback we engage in makes them think for themselves. Feedback for Learning offers a process to enable that to happen


Archer J, State of the Science in Health Professional Education. Effective Feedback: Medical Education 2010:101 – 108
Cantillon P, Sargeant J, Giving feedback in Clinical Settings BMJ 2008: 337a 1961
Schon D, From technical rationality to reflection in Action in Schon D, The Reflective Practitioner: how professionals think in action. London basic books 1983 21 - 75