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and Wilson [ 28 ] as the psychological immune system which may limit the extent to
which feedback is sought or implemented by a learner. Learners first require a cer-
tain amount of internal confidence in order to be prepared for feedback. This will
allow them to seek out feedback and deal with the inevitable negative constructive
assessments necessary for improvement [ 29 ]. Much of a resident’s internal confi-
dence will have been established prior to beginning residency, but it is important for
us as educators to recognize where they are starting and do what we can to develop
an appropriate level of confidence in our learners. This is also good to keep this in
mind regarding all of our interactions with younger learners such as medical stu-
dents or undergraduates and understand how much influence we can have on their
future. After the internal confidence of the resident has been taken into account, the
feedback will be most effective if the learner perceives the feedback to be truthful
and delivered with their best interests in mind [ 29 ]. Accurate feedback will best be
given by a direct observer of the evaluated task, and learners are more likely to trust
and incorporate feedback from direct observation as opposed to second- or third-
hand reports [ 24 ]. The timing of feedback also has an impact on its accuracy and
precision. Williams and colleagues have demonstrated that a delay of greater than
72 h was associated with a significant decrease in the quality of the operative assess-
ment as demonstrated by a loss in detail and nuance in favor of broad generaliza-
tions [ 10 ]. These aspects of effective feedback highlight the weaknesses of the
standard semiannual evaluation in which feedback may be based on direct observa-
tions of multiple faculty members but is typically relayed to the resident months
later by a single person (i.e., the program director) who only observed a fraction of
the operative performances.
Of course, simply providing an accurate assessment is not enough if our goal is
incorporation of the feedback to change behavior and improve performance. For a
resident or any other learner, to translate feedback into behavior modification
requires motivation. This begins with the resident understanding that they have to be
the one actually doing the learning and implementing the changes. They must have
an understanding on the target performance, how their performance differs, and how
they can narrow that difference. A teacher simply prescribing specific actions to
take will not be as effective as the learner working toward a clear understanding of
the final goal and how those actions fit into that goal [ 27 , 30 ] and further developing
their sense of autonomy (i.e., the learner has ultimate control over future changes to
their performance) [ 27 ]. This self-directed learning will be further supported by
fostering a healthy relationship between the teacher and the learner. This allows for
the feedback to be a collaborative process sought by the learner in which the learn-
ers work toward a set of clear predetermined objectives as opposed to one imposed
by the teacher with an arbitrary standard of the teacher’s choosing. This, combined
with a neutral, objective, nonjudgmental tone, moves the experience from a perfor-
mance focus to a learning focus [ 23 , 27 ].
Within the actual feedback session, certain techniques will both increase the
effectiveness of the feedback given and further improve the relationship between
the teacher and learner for future sessions. First the teacher should ask for the resi-
dent’s own thoughts and feelings about the case. This will allow the faculty member
M. Mirza and J.F. Koenig