Beyond the Feedback Sandwich:
Fun Tools for Improving Feedback Skills
• Describe rationale for giving feedback
• Discuss barriers to giving effective feedback
• Practice analyzing teaching videos
• Describe process of giving effective feedback for lifelong
learning – including the incorporation of reflection into the
Rationale for Giving Feedback
• Without feedback, mistakes go uncorrected, good
performance is not reinforced, and clinical competence
is achieved empirically or, not at all.
• Good feedback promotes the skill of reflection, which is
essential for the development of expertise and lifelong
• It’s required by the LCME and ACGME.
Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781.
Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA 2009;302:1330-1331.
• (Reinforcement or correction) + Explanation
• Keeps learner on course to meet goals
• No judgment against external standards; no matter where
learner is in relation to external standards, feedback is
always helpful
• Best if given immediately after the performance or at some
time soon after, when the learner still has time to
demonstrate improvement
• If done well, the learner does not feel judged, enhances
capacity for reflection, and therefore lifelong professional
Ende Principles of Good Feedback
• Aligns the goals of teacher and learner
• Is well-timed and expected
• Is based on first hand observation
• Is regulated in quantity and limited to remediable behavior
• Is phrased in descriptive, non-evaluative language
• Deals with specific performance
• Deals with decisions and actions rather than assumed
intentions or interpretations
Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781.
What are the biggest
challenges to giving good
Why are educators failing at feedback?
1) Not learner-centered/without awareness of the learner’s
perspective or self-assessment
2) Overpowering of affective reactions to feedback / a failure
to separate the behavior and the person (for teacher and/or
3) Unsuccessful feedback teaches learner to fear or avoid
feedback in the future
Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA 2009;302:13301331.
Domains of feedback
• Knowledge
• Skills
• Attitude
“Sleeping” Video: Part 1
• Take notes on what you observe:
– What did the residents think of the student?
– What feedback was delivered?
– How did the student respond?
• Discuss with your partner
“Sleeping” Video: Part 2
• Here are the same residents after additional training
– What was done differently?
– Do you detect a different structure to the feedback?
– How did the student respond?
• Discuss with your partner
What more could the resident have done?
• Make explicit what was learned:
“This is an important opportunity to learn how to balance
your personal and professional lives. When something in
your personal life starts to impact your professional
performance, you need to tell colleagues and ask for help in
handling the situation and/or ensuring your professional
obligations to others are fulfilled.”
More advanced
• Responsible and reliable
• Self directed: takes
responsibility for learning and
• Industrious and dedicated
• Enthusiastic and motivated
• Appropriately respectful and
• Honest and trustworthy
• Actions based on accurate
understanding of perspectives
and needs of others: including
patients, team
• Overcomes performance
preoccupation to focus on
patients and learning
The Old Feedback Sandwich
The New Feedback Sandwich*
*Lyuba Konopasek, MD; in prep for publication
• Ask learner to assess own performance first
• Begins a conversation – an interactive process
• Assesses learner’s level of insight and stage of
– Less threatening: separating behavior from “self”
– Promotes reflective practice
• Tell what you observed: diagnosis and
–React to the learner’s observation
• Feedback on self-assessment
–Include both positive and corrective elements
• “I observed….”
–Give reasons in the context of well-defined
shared goals
Ask (again)
• Ask about recipients understanding and strategies for
– What could you do differently?
– Give own suggestions
– Commit to monitoring improvement together
Limit the Quantity
BEFORE Giving Feedback:
Prepare Effectively
• Set a time – major feedback should not take
student by surprise
• Plan what you will say
• Make sure that you have enough information
• If feedback is second hand, try to obtain
specific, documented behaviorally based
AFTER Giving Feedback:
Reflect on How it Went
• What was effective?
• What could be done differently?
–Were you well prepared?
• Future strategies
• Do you need to document?
• Do you need help?
Benefits of Ask-Tell-Ask
Learner centered incorporating the learner’s perspective
Active and interactive
Avoids assumptions or judgment
Reflection may make it easier to separate the behavior
from the person
• Promotes lifelong skill of reflection
These are basic communication skills and allows us to “put
the diagnosis before the treatment”
Branch J, Paranjape A. Feedback and Reflection: Teaching Methods for Clinical Settings. Academic
Medicine. 2002;77:1185-1188.
End with Ende
“The important things to remember about feedback
in medical education are that (1) it is necessary,
(2) it is valuable, and (3) after a bit of practice and
planning, it is not as difficult as one might think.”
--Jack Ende, MD
Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781.
Lyuba Konopasek, MD
Andrew Mutnick, MD
John Encandela, PhD
Gingi Pica, MPH
Center for New Media
and Technology:
Michelle Hall, BS
Glenda Garvey Teaching
Academy, Columbia
Maya Castillo
Thomas Hooven
Benjamin Kennedy
Daniel Vo

Beyond the Feedback Sandwich