Who would dispute the idea that feedback is a good thing? Both common sense and research make it clear: Formative assessment, consisting of lots of feedback and opportunities to use that feedback, enhances performance and achievement [1]. John Hattie (2008), whose decades of research revealed that feedback was among the most powerful influences on achievement, acknowledges that he has “struggled to understand the concept” [2]. Many writings on the subject don’t even attempt to define the term. To improve formative assessment practices among both teachers and learners, we need to look more closely at just what feedback is—and isn’t.

The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to document trainee performance, and provide more continuous feedback during training. Specifically, the goal of any surgical residency is to prepare residents to not only be board-certified surgeons, but also achieve competency to become good physicians [3, 4]. Improvement in operating skills, for example, requires constant feedback between teacher and learner to promote reflection on performance [3, 4]. In the new era of milestones, effective feedback is critical in developing competent surgeons; however, studies report that feedback can be lacking [5, 6]. Orthopaedic surgery training programs utilize the apprenticeship model, based on the idea that the master teaches the trainee, and the trainee engages in experiential learning or learning by doing [7]. Resident feedback, in the apprenticeship model, is an essential part of creating competent orthopaedic surgeons. Traditionally, feedback in residency training was at the end of rotation, informal, subjective, and vague [8]. There were problems with this type of feedback in that the timeliness and quality of the evaluation were suboptimal [6, 9]. One study of orthopaedic residents at a single institution showed that almost half of residents felt that they received immediate surgical feedback less than 20% of the time [9]. Moreover, a department review of 1556 faculty evaluations of residents over 4 years showed that the average time to receive written feedback was 43 days after the rotation ended [9]. Feedback is necessary for the growth of the resident into a competent surgeon. In a time now with emphasis on milestones and competency curriculum, effective feedback is a critical component of residency training and faculty are sought out to provide high-quality feedback that encourages residents to engage in deliberate practice to refine their skills [10, 11].

Feedback can be defined as “specific information about the comparison between trainee’s observed performance and a standard given with the intent to improve trainee’s performance” (p. 193) [12]. The term feedback is often used to describe all kinds of comments made after the fact, including advice, praise, and evaluation. But feedback is ill defined. Basically, feedback is information about how we are performing in our efforts to reach a goal. I tell a joke with the goal of making people laugh, and I observe the audience’s reaction—they laugh loudly or barely snicker. I teach a lesson with the goal of engaging students, and I see that some students have their eyes riveted on me while others are nodding off. Because the term feedback may be used to describe a number of scenarios, it can often be overlooked by residents. Defined another way, feedback is the process of the resident seeking to find out more about the similarities and differences between their performance and the target performance [13, 14]. This definition emphasizes the active role of the resident, as they have to be motivated in implementing the learning plans to achieve a target performance [13–16]. Specific feedback must instruct the resident on what the target performance is and how their performance differs [13, 15, 16]. Although there is no consensus on the definition of feedback, one review found that three concepts emerged: feedback as information, feedback as reactive to information that is given, and feedback as cyclic, involving information and reaction [12]. To expand on this, feedback as information is essentially the information on the learner’s performance, with the focus on content of the information. Feedback as a reaction differs, in that there is an interchange of information delivery and reception, where the focus is on the interaction with information. Lastly, feedback as a cycle is when the output is fed back as the new input to modify and improve future outputs, with the focus being on receiving information, responding to the information, and improving response quality [12].

There are many forms and avenues for feedback including formal or informal, clinical and surgical, reinforcing or corrective, and verbal or written. Ultimately, there are two main types of feedback: formative ongoing feedback which occurs on a regular or an ad hoc basis, and summative (formal) feedback which is typically shared during annual or semiannual performance reviews. Formal summative feedback usually occurs in a meeting-type environment or as a formalized document, such as an individualized learning plan. Formative feedback (informal), on the other hand, is characterized as “on the fly” and less directive. The feedback may address behavior in the operating room or the clinic, with each situation addressing different aspects of the resident’s performance. All feedback is not corrective; if a resident is performing well, feedback can be given to reinforce the good behaviors and point out performance strengths. Lastly, feedback may be written or oral, with written feedback usually comprising some sort of numerical grading system that allows for tracking of residents’ progress over time and also a comments section. Simple oral feedback models have been developed to allow for real-time ongoing assessments, both in the clinic and in the operating room.

Regardless of the form, the seven main components of high-quality feedback are goal referenced, tangible and transparent, actionable, user friendly, timely, ongoing, and consistent [1, 2, 5, 17]. Feedback, most importantly, should avoid disrespectful or personal comments that have a judgment or focus on the personality and not on specific behavior, not be goal oriented, and provide no constructive suggestions for improvement [18, 19].

Research has found that choosing the right types of feedback strategy and content specific to the learning target is the most important for student achievement. Definitions and examples of types of feedback are included below. It is important to remember that any feedback given must be cognizant of tone, clarity, and specificity which are critical for any type of feedback.

Written feedback : Feedback that is in the written language and is often provided in the middle and end of a rotation and is usually formal: The evaluative form usually has a component of written feedback. With the goal for residents to improve performance or address areas of weakness, short phrases of nonspecific comments are suboptimal such as “Good job” or “Hard worker.” The faculty member needs to elaborate on their overall impression of the residence’s performance. For instance, explain why the resident did a good job, and offer goals and plans to achieve them that are tailored to the resident’s experience level. Integrate “sandwich-type” evaluation or other specific models; add examples and be specific and directive in how resident can improve.

Verbal feedback: Feedback that is spoken and should occur on a daily basis that is focused on improvement of the resident’s clinical and surgical skills throughout the rotation: The majority of the time this type of feedback is informal because it takes place “on the go.” When giving this type of feedback faculty need to be aware of critical components including the language used, location, identifying and defining the teachable moment, and tone. Language and tone are important because you can say the same thing, and have it interpreted differently based on whether an aggressive or a calm tone and inviting or open language were used. Confrontational tones (aggressive, condescending, and sarcastic) will put the resident into a defensive mode and they are unlikely to act on the feedback.

Formal feedback : Feedback that is provided as part of a summative assessment: The feedback is mostly written, and covers the resident’s performance both clinically and surgically. There may be a verbal component if the faculty member and resident meet to go over the assessment. This type of feedback follows the resident throughout their training and allows for improvement to be seen longitudinally in the long term. An important note is that the faculty member needs to be specific and descriptive because that will allow for a more accurate measure of the resident’s improvement longitudinally throughout residency.

Informal (ongoing) feedback : Feedback that takes place on a day-to-day basis with the goal of improving the resident’s performance for that rotation: The feedback is usually verbal, and can occur in the clinic or operating room. When giving this feedback, the faculty member needs to help the resident set a goal for improvement and a plan to get there. For example, saying “your shoulder exam needs to be improved” is not as helpful as more specific feedback like “your shoulder exam lacked testing for impingement or strength” or “I have found that this book chapter is a great resource, please read it tonight and we will go over it tomorrow.”

Any good model of delivering feedback should assess orientation and climate, and include elicitation, diagnosis and feedback, improvement plan, application, and review [18]. It is best to let the resident know ahead of time that there will be a feedback session to orient them for the session, and it is the faculty member’s responsibility to provide a relaxed and respectful climate [18]. This also allows the resident to manage their duties and optimizes the ability for them to be mentally engaged in the session.

To start the session off, elicit from the resident a self-assessment and use open-ended questions about the resident’s performance [7, 18, 20]. This is important because it allows you, as faculty, to understand the resident’s perception of their performance, to engage them in the process, and to begin to formulate a focus area for improvement. During the conversation, provide reinforcing and corrective feedback, as well as responses (diagnosis) to the observations of the resident [18]. The faculty should also use their expertise to help clarify misunderstandings, set priorities, and offer suggestions for improvement [13].

Next is to develop specific strategies for improvement, or improvement plan, by giving your suggestions, and asking the resident how they can improve [18, 21]. The most important step is the resident applying the discussed strategies to the present time and, as a faculty member, it is your job to monitor the development and application of the improvement plan [18]. Lastly, have the resident repeat back what was discussed at the session. This review allows for identification of any misinterpretations, and allows the faculty member and resident to agree on a timeline for change [18]. The goal of the session is for it to be a dialogue and constructive, not paternalistic, condescending, or insulting [13]. Having the resident engaged in his/her own strategy for improvement will lead to the resident being more likely to implement the changes, and ultimately allow them to be a better orthopaedic surgeon [13].

A simplistic model of feedback recently propagated is the One-Minute Preceptor model. This model has been used in many leadership programs, emphasized in orthopaedic surgery educational programs, utilized by faculty in graduate medical education, and provides a simple yet effective real-time model for providing feedback to residents [22, 23]. In this model the first step is getting a commitment from the resident by finding out their diagnosis or plan or how they think they did. Next, you want to probe for supporting evidence to understand why the resident developed that thought process. After that, the faculty should teach general rules by giving the resident “take-home points” aimed at the resident’s area of gaps in knowledge. The fourth step is to reinforce what was done well, positive feedback, and what the resident should continue to do. Lastly, provide constructive feedback to correct any errors that you identified along with suggestions on how to improve.

Pendleton’s rules are another popular conventional model for feedback [24]. The first part is the resident’s self-assessment of what they did well. The faculty member then reinforces what was done well, as well as what skills were necessary to achieve the successful outcome. Next, the resident gives another self-assessment, but this time on what could have performed better. This includes analyzing the skills used that lead to these suboptimal results. The faculty member can then suggest alternative ways to achieve the target level of performance. The benefit of this approach is that strengths are discussed first, which allows for a comfortable environment to be created with a receptive resident.

Another more simplistic feedback model is the feedback sandwich [24, 25]. In the first step of this three-step process the faculty member delivers positive feedback to the resident (top layer of bread). Next, the faculty member gives constructive feedback based on the resident’s performance on a certain task or task (meat of the sandwich). Lastly, the faculty member ends the sessions with more positive feedback (bottom layer of bread). This model is generally well received by the resident as the guidance for improvement is comfortable for the learner. However, the resident may take away only the positive comments provided in the encounter and dismiss the constructive criticisms. Without the resident focusing on the constructive criticism, the goal to improve performance can be missed.

Finally there is also the CAST model for delivering effective feedback to residents [26]. CAST stands for Continue, Alter, Stop, Try. Initially during the encounter, the faculty member acknowledges the behaviors that the resident should continue to do. Next, the resident is informed of behaviors that need to be altered so that they can become strengths. After that, the faculty member discusses what activities need to be stopped because they do not add value, or are applied the wrong way. Lastly, the faculty member offers new skills to apply and practice for the resident to try the next time.

Similar to the CAST model, the SKS method is a three-step feedback method that stands for Stop, Keep, Start [27]. This method is one that is usually used by the resident who seeks feedback. The first step addresses what the resident should stop doing. The second step encourages residents to keep doing certain behaviors or maintain the positives. Finally, in the third step, the faculty encourages the resident to start doing or to try a new behavior. This method allows for a very brief encounter that can be impactful. Furthermore, this is a model that can be utilized by residents to regularly seek feedback. The SKS method does rely on the resident to be self-reflective and receptive to feedback because a perceived strength may actually be viewed as a weakness by faculty.

The one-on-one environment of the clinic is a crucial time to provide low-stakes formative assessment and constructive feedback [28]. The clinic allows the faculty member to evaluate aspects outside of the operating room, such as communication, empathy, diagnostic skills, exam skills, interpretation of imaging, and decision making and critical thinking skills. Try to avoid giving a resident feedback near the patient rooms or public areas, as this may make the resident uncomfortable and hinder an open discussion. Again, it is important to emphasize that the feedback session is a dialogue, and the resident should be actively participating in the discussion. A goal after each day of clinic is to have a brief debriefing meeting with the resident, and address goals set and previous plans for improvement, if those goals have been achieved, modifying previous plans for improvement, and creation of new plans of improvement. The easiest way to implement the short debriefing processes is to do it after the last patient is seen; this takes a maximum of 5 min. Focusing on one area of improvement allows for the session to be brief, effective, and allow everyone to finish their clinic work.