Episode Transcript
[VR] Hi, my name is Vince Raikhel. I am an assistant professor at the University of Washington in General Internal Medicine.
[TF] And I’m Tyra Fainstad, an associate professor at the University of Colorado in General Internal Medicine.
[VR] We’ve teamed up to bring this podcast to you. Today, we will be discussing the Feedback Alliance: an intriguing way of considering the feedback conversation with a focus on supporting the learner side of the process. We’re calling it the feedback alliance because it is a pact between the teacher and the learner to facilitate feedback. We’ll talk about the current state of feedback, the importance of psychological safety to the learning climate, briefly explain learner mindset theory, and finish with strategies to encourage learners to solicit and drive an effective feedback conversation. At the end of this podcast, you should be able to describe the feedback gap, diagnose a fixed-mindset learner, and use evidence-based strategies to encourage psychological safety in the learning climate and support a growth mindset that empowers feedback seeking in your learners. Let’s get started!
[TF] Feedback has consistently scored as one of the lowest subjects for decades on the annual ACGME resident survey. It has fallen below burnout, work hour restrictions, and all other educational questions. In 2019, only 72% of residents reported being “satisfied” with feedback. “Satisfaction” has a low bar of just a 3/5 or higher on a Likert scale, and the mean score for feedback was a 3.6.
[VR] Each year faculty take a mirror survey for the ACGME, and invariably, 99-100% perceive giving adequate feedback to trainees. This inconsistency, residents not satisfied with their feedback, yet faculty believe they give great feedback, is termed the feedback gap. This phenomenon has been observed repeatedly in various studies looking at many different specialties in medicine and has persisted for years despite an enormous effort to provide faculty development on feedback delivery.
[TF] Many strategies have been proposed to address this problem, most of which focus predominantly on the feedback giver: increasing feedback frequency and quality, sign-posting or “calling out” feedback more obviously, as well as efforts to make feedback mandatory. One of the simplest ways to increase resident feedback satisfaction, however, focuses on the learner by tapping into their intrinsic desire to learn and supporting their feedback-seeking skills for their learning goals. If learners identify skills that they would like feedback on and then subsequently receive feedback on that skill, they are more likely to remember it later.
[VR] Sounds straightforward Tyra, but I imagine like many ideas in education, this is easier said than done.
[TF] That’s right Vince. For this to take place we need two ingredients: the learner needs to have a growth mindset toward their learning, and they need to feel safe to show their deficits in other words, they need a psychologically safe learning environment. When these two components are both present, we can truly foster a meaningful and productive educational alliance with our learners that empowers them to flourish as learners.
[VR] So, what are the barriers to this simply occurring? Well, it turns out there are a lot! Challenges to fostering a rewarding feedback alliance can stem from the learner, the teacher, the learning climate of that relationship, or the overall learning and practice environment or “culture” that they are working in. We’ll discuss challenges that may stem from the teacher in a follow-up podcast. For today, let’s focus on issues related to the learner and the learning climate.
[TF] Take a moment to think back to your training as a medical student and resident. Were there times when you felt hesitant in soliciting feedback from a supervisor? Vince, I’m wondering if there were teams that you worked on that instinctually felt unsafe to ask for feedback?
[VR] I know these resonate with my experience as a learner. In fact, I can recall very few instances where I felt comfortable asking for feedback. During one of my clerkships in medical school I was working with a team that gave me little guidance on what I should be doing. Nobody told me what patients to work with or even when I should be in the operating room. All I was told was that I needed to be “on point.” What did that even mean? I was left trying to read the tea leaves of what my role was and how I functioned on the team. When I managed to find my way to the operating room at the right time, I was left totally unsure where I should be standing or what I should be doing. I distinctly recall the sensation of being actively ignored. In what universe would a learner ever feel comfortable asking for feedback in this situation? And while it was never explicit, it was clear to me that asking for feedback ran the risk of resulting in a demerit on my evaluation. As I moved on to residency these challenges followed me. I remember straining to conjure questions that wouldn’t reveal my true lack of knowledge on a given topic but would rather present me as someone ready to handle the minutia and esoteric details of whatever topic was being discussed. Of course, this wasn’t what I needed, and was a real determinant to my learning. The weight of my evaluations overshadowed my ability to acknowledge my desire and need to learn. This was true for me, despite evaluations being significantly less impactful for my career at that point in residency than they had been in medical school. It was a lesson that was hard for me to unlearn.
[TF] That sounds challenging, and I’m sure is an experience that has been shared by others unfortunately. A lot of what drives how we behave as learners has to do with the learning environment, and how it promoted, or in Vince’s case impeded, his psychological safety. Psychological safety refers to the learner’s perception that they can take risks, expose vulnerabilities, and share ideas without fear of judgment or shame. Reflecting on Vince’s experience, it’s understandable why it can be challenging to support a psychologically safe learning environment in medical education. So, what are some of the major contributors to learners feeling as though they are working in a learning environment with suboptimal psychological safety? Dr. Adelaide McClintock, an assistant professor in general internal medicine at the University of Washington, has described barriers surrounding psychological safety in medical education. It turns out many factors are baked into the educational structures that we often work in. Let’s discuss three of them.
[VR] I wasn’t surprised to learn that hierarchical systems, which have a strong presence in medical training teams play a strong role. While they can be important in regard to patient safety and care delivery, these systems can also serve to isolate early learners who rank lower in the team’s hierarchy. Hierarchical systems also diminish the psychological space of early learners while magnifying the psychological space of more senior members. This can lead to increased barriers in communication from more junior members of the team. As a result of these challenges, junior members have a higher risk of feeling isolated, unengaged, or undervalued.
[TF] The second structure are regular formal assessments and evaluations are an established component of the medical training experience. While efforts have been made to standardize evaluations with rubrics based on objective observations, significant challenges remain in encouraging learners to be vulnerable in a setting where they are also being evaluated. Learners can feel as though they are always “on” or performing for their superiors, which can have profound impacts on burnout and learning.
[VR] And third, lack of clear expectations is another powerful force that can compromise psychological safety. If learners are unclear of their role, and thus unclear on what they are being evaluated upon, it can lead to their cognitive energy being used to “decode” the evaluative process, as opposed to developing their knowledge and skills.
[TF] While it may seem as though the weight of our institutions and traditions of training can make it challenging to support a psychologically safe learning environment, there are strategies we can undertake to turn the tide. Dr. Amy Edmondson has described three pillars of developing psychological safety in a clinical environment: setting the stage for our learners, inviting their participation, and responding productively. Let’s discuss how we can implement these ideas. The first technique is simply setting expectations. This is obviously the opposite of the lack of clear expectations barrier we discussed earlier. Sitting down with your team or learner to let them know what will be expected of them includes both logistical as well as learning expectations.
[VR] By including the learning process in our initial expectations, we have the potential to plant the seed of a growth mindset from the beginning of our relationship with a learner. When I first meet with a group of learners that I will be working with, I tell them that I expect all of us, including myself, to ask questions when we don’t know something.
[TF] Second, once we have set clear expectations and developed a shared mental model for how learners can engage in clinical care, the next step is to encourage their participation. In order to do this in a way that engages them and maintains patient safety, we need to scale their independence to a level that is scaffolded to challenge while not overwhelm them. Learners regularly endorse autonomy as an important factor in their clinical education. Empowering autonomy promotes trust and ownership from team members. It also counters some of the challenges related to hierarchical systems that we discussed earlier.
[VR] I don’t know about you Tyra, but finding out what degree of autonomy a learner is ready for can be a challenge unto itself and can be supported by the final technique for supporting a psychologically safe learning environment: getting to know your learners and responding to them productively. I would encourage everyone to meet with your learners and get to know them as individuals. Learners thrive when they feel as though their teachers are invested in their growth and genuinely care about them. And this starts with us being curious about who they are.
[TF] What is important to them outside of their clinical work? Ask them about their previous rotations and experiences. What has been challenging? What has been rewarding? What are their goals? Getting to know your learners is a key component of developing a safe learning environment that is robust enough to work through the many challenges that arise in clinical medicine. This really energizes our communication with our learners in ways that extend far beyond the evaluations and assessments that, as we discussed earlier, often serve to blunt learners’ participation and engagement.
[VR] Now that we have discussed several techniques that can support a psychologically safe learning environment, let’s shift to discussing how we can support our learners to increase their feedback seeking. As we did with psychological safety, let’s start by identifying some common barriers to this important concept. Afterwards we’ll shift to discussing concrete ways to support feedback seeking from our learners.
[TF] There are, as you can imagine, many barriers a learner can have to asking for feedback. First, fear of revealing deficits. This is far and away the most common reason for avoiding feedback, learners are afraid that they will “show” their supervisor their weakness and therefore be judged as incompetent.
[VR] Absolutely a fear that I had during training. Second, fear of the feedback turning into a grade or evaluation. This piggybacks off the first point, but is an important and not unfounded fear. Learners are acutely aware that formative feedback is one of the biggest contributors to summative evaluation. Thus, they hope to only get positive perspectives for a high-stakes assessment. Fortunately, this is less common in residency where evaluations tend to mean much less than in medical school, but the imprinted lesson from early training can be hard to dispel. Third, learners may simply be having a sensitive or defensive day. Maybe the learner has been up all night. Maybe their cat died yesterday. If there is some external reason that they feel would bring them to tears, anger, or other awkward confrontations, they may avoid asking for feedback until they are on solid ground.
[TF] These common reasons for learners to avoid formative feedback relate to a fixed mindset. Carol Dweck, a general education researcher, first coined this growth versus fixed mindset theory over 30 years ago. In working with grade schoolers, Dweck found that some students had a fixed mindset about their abilities.
[TF] That is, they thought intelligence is just a fixed trait that you have a certain amount of and that’s it. This mindset has been shown to make students afraid to try because they’re afraid to look dumb. Their main goal is to look smart at all times and at all costs, and their whole lives are oriented toward avoiding tasks that might show a deficiency. They believe that if you have ability, you shouldn’t need effort. Other students had a growth mindset, where they believed that intelligence can be developed through effort, learning, and mentorship. Their main goal is to learn at all times and at all costs. They believe that effort is what brings ability, and mistakes are a natural part of learning. Her landmark study measured the mindset of hundreds of seventh-grade students and followed them over time. Despite identical test scores at the onset of the trial, the fixed-mindset students dropped almost immediately and continued to diverge over the next few years.
[VR] I think a lot of us, including myself, can identify with a fixed learning mindset at some point in our learning journeys. When I was in high school there was a point at which math became significantly more challenging for me. This was likely simply the result of the material progressing and becoming more challenging, but I began to tell myself that math simply wasn’t something I was good at. No matter, I was planning on going to a music conservatory for college to study classical composition. Well, a few years later, when I decided to transition to a career in medicine, the first premedical prerequisite I needed to pass was Calculus. Learning that material was certainly challenging, requiring me to invest significant effort and time. At the end of it, I realized that there was nothing inherently unmathematical about me; I just had not approached the learning with a growth mindset when I was younger.
[TF] Medical training, with its high-stakes, achievement-based culture that is often in direct opposition to psychological safety, unfortunately fosters a fixed mindset. Fortunately, it turns out that our mindset is not global or permanent. People have different mindsets toward different areas of their lives, you may have a fixed mindset around an athletic activity, but a growth mindset toward learning how to cook or garden.
[VR] This is such an empowering framework. Mindset is also not permanent, and with awareness and coaching even the most fixed of mindsets can shift. So, what can we, as educators, do to help our learners develop a growth mindset? Here are three concrete ways that we can encourage our learners to develop a growth mindset. First, model feedback seeking. For me this involves asking for feedback from my learners on a specific task or skill that they will observe. For example, most recently I asked learners for feedback on my communication skills with patients while the team is doing morning rounds. Specifically, I wanted to know if the learners felt as though they were the primary communicator with our patients, and if I ever needed to step in to clarify something or offer my thoughts, that I handed the discussion back to the learner afterwards. I prepare the learners to give me feedback by sharing this as a personal learning goal and letting them know that I will ask them for feedback on this skill. In doing so, I hope to model the growth mindset for my learners by eliciting their feedback for my continued growth.
[TF] This is a natural place to connect our approach to established feedback frameworks. The ADAPT model: Ask, Discuss, Ask, Plan Together, emphasizes creating a collaborative understanding of the learner’s perspective and working together to develop a plan for improvement. Similarly, the R2C2 model, Relationship, Reaction, Content, and Coaching, emphasizes first establishing a trusting relationship, exploring the learner’s response to feedback, making sense of the feedback content together, and ultimately developing a collaborative action plan. Both frameworks reinforce a central principle of our approach: effective feedback is not simply something delivered to a learner; it is a collaborative process of understanding, reflection, and planning for growth. We are not suggesting that educators need to follow either model rigidly. Rather, both frameworks reinforce an important principle of feedback literacy: effective feedback is a conversation, and the learner should have an active role in making sense of the feedback and deciding how to use it. That fits naturally with our emphasis on feedback seeking and a growth mindset.
[VR] The next step is to, normalize the existence of a fixed predisposition and explicitly teach learners about mindset theory. Telling a learner about times that you, as an attending, have grappled with your own fixed mindset helps bring awareness to the phenomenon and also helps learners feel less “at fault” for their own. In truth, the reason that most of us have fixed mindsets is because of our training and practice environment, and normalizing this can be a powerful moment for learners to shift their perspective. Like so many things, once we give a characteristic or trait a name, we are able to have a conversation about it. Having this language and understanding can often be the first step toward self-assessment of a fixed learner mindset.
[TF] Third, praise process in addition to outcomes. This is hard since we are in a field that naturally focuses on outcomes. Praising a learner’s process can help give opportunities for them to ask for feedback on various parts of the process, and is an inherent reminder that hard work, rather than natural ability, is responsible for most outcomes. This looks like noticing hard work that produces an outcome at least as much as noticing the outcome. It also involves observing and noting improvements in skills or knowledge, even if further progress is needed. For example, after working with a resident in placing a central line, I may share that their skills in using the ultrasound to follow their needle tip have become much more accurate and have decreased the amount of time they have needed for the initial part of the procedure. I might also recognize the fact that I have seen them in the simulation lab or looking at online resources before the procedure with gratitude. This can all be true, despite the learner not demonstrating the necessary skill for the entire procedure to be ready to independently place central lines. The process of learning a new skill goes through many phases, and we do well by our learners to note and observe their progress.
[VR] If you’ve noted that there are similarities between supporting a psychologically safe learning environment and promoting a growth mindset in your learners, you’re right! These concepts that benefit from understanding our learners as individuals and modeling the process of learning can absolutely be synergistic and will naturally complement one another. That said, we want to end by acknowledging that introducing new habits as an educator is not easy. We are, after all, asking you to have a growth mindset in your skills as an educator! I personally struggle to integrate all of the best practices that we’ve discussed on a regular basis, and at times can slip into a fixed mindset with my teaching.
[TF] Remember that the overall goal is to create a learning environment where your learner feels encouraged to ask for formative feedback. I suggest trying out each of these tips to find out which best fits your teaching style and go from there. If you aim to cultivate a psychologically safe learning climate and encourage a growth mindset in your learners, you are contributing to a culture that we know will positively impact our learners. Thank you so much for listening, we hope you enjoyed this Toolbox podcast!
