Giving Feedback that Sticks and Receiving it With Purpose

The importance and efficacy of feedback as an educational tool is well established within medical education literature, with widespread consensus that it is essential for learner development.(1) Reflecting this, the Accreditation Council for Graduate Medical Education (ACGME) designates feedback as an “essential and required” aspect of resident training across all specialties. While overlap exists, it is important to distinguish feedback from assessment: feedback is formative and learner-directed, while assessment informs programs of learner progression over time.(2) Without effective feedback, strong clinical practices are not reinforced, poor performance may go unrecognized, and remediation strategies cannot be implemented.(1)

Despite its recognized importance, numerous barriers threaten the credibility and usefulness of feedback. In particular, the emergency department (ED) presents unique challenges: rapid workflow, high patient acuity, constant interruptions, task-switching, and varied trainee experience levels (3,4). The shiftwork-based nature of emergency medicine (EM) further complicates feedback delivery, as learners frequently have single, high-volume encounters with multiple attendings, limiting opportunities to form trust-based relationships critical for credible feedback.(3)

These challenges contribute to a recurring discrepancy between resident and attending perceptions of feedback quality in EM settings.(5) This gap can undermine credibility and receptiveness. Although the value of feedback is widely acknowledged, there is variation between recent guidelines published on how to deliver feedback optimally within the ED environment. This blog post will aim to address this gap via the following objectives:

1. Briefly outlining differences in feedback types and discussing ED-specific challenges to feedback delivery
2. Exploring what constitutes effective verbal feedback delivery & content
3. Briefly exploring the effects of language and implicit biases within feedback
4. Discussing the concept of ‘feedback literacy’ and how to effectively solicit and receive feedback

At the end of this post, we can then apply this approach to how to provide feedback to a resistant learner, and how to deliver critical corrective feedback.

Objective 1: Differences in feedback types.

Feedback in medical education varies by setting and delivery method. Systems like Competency By Design (CBD) place feedback at the core of training frameworks.(6) CBD integrates multiple approaches—direct observation, multi-source feedback, workplace-based assessments, and competency committee evaluations—to provide a comprehensive view of resident performance. As feedback becomes more diverse and central to assessment, understanding each method’s impact on trainees is increasingly important. Below is a detailed, but not exhaustive, summary of different feedback types:

Feedback and Coaching

The traditional approach to feedback has always been geared towards an educator-centered approach, where feedback is often thought to focus on aspects relating to past performance and is often delivered unidirectionally, from teacher to learner.(12) However, feedback paradigms are shifting to become more learner-centered(13) and taking on more similarities to the traditional definitions and roles of coaches.  Within coaching, the focus falls on ongoing development and guiding the learner towards future improvement via an active dialogue focusing on goal setting and support.(12) While the nature of coaching could have a dedicated blog post to itself, it is important to acknowledge this change in feedback structures and remind ourselves that our primary goal in providing feedback is to support the growth of learners, rather than criticize. By outlining key methods for the process of enhancing feedback delivery, learner involvement can become more active in the process and transform feedback into a more effective and applicable learning tool.

Objective 2: Effective verbal feedback delivery and content

Despite a lack of unifying guidelines, there is broad agreement among medical education experts, trainees, and accrediting organizations on the core elements and features that define effective, high-quality feedback. These sources all recommend that feedback be timely, clear, specific, balanced, and actionable, no matter the setting or method of delivery.(9) Understanding these characteristics, the process of delivering ‘effective’ feedback should be broken down into the process of delivering feedback as well as the content of the feedback itself, based upon guidelines published by Lefroy et al.(14) Several other recent guidelines have been published with extensive and specific recommendations for delivering effective feedback(14), some specific to the ED setting, which will be used to breakdown the importance of each of the characteristics identified above.(3,9)

Furthermore, it is important to acknowledge that institutional cultures around feedback are hugely important in shaping how feedback is given and received. This is yet another subject which warrants its own separate blog post, but it is crucial to acknowledge the impact of this in centers where feedback may not be a regular established part of medical education and practice.

Feedback Process – Timely Delivery

Before feedback delivery begins, it is important to address any learning goals the trainee may have at the start of the shift, as this helps shape the key elements of effective feedback. Early discussion of specific and feasible goals—such as a particular EPA, skill, or procedure—can anchor feedback content and increase its perceived credibility.(15) This also allows the assessor to plan for direct or indirect observation and determine appropriate timing for feedback delivery.(3,4,14,16)

The optimal frequency and timing of feedback remain uncertain and understudied. Given the challenges of the ED environment, ensuring protected time for feedback is essential.(3) Learners value frequent and timely feedback and rarely find delayed feedback useful. (3,4,9,15,17–20) Moreover, different types and levels of feedback may require different delivery timing.(14,21,22) The timing of feedback can also be based on the competence level of the learner and or the complexity of the task being observed or assessed.(14) Some examples include:

• Providing concurrent (during the task), corrective feedback during task acquisition for clinical skills or procedures(22,23)
• Avoiding immediate correction during tasks where fluency is a key component to master (ex. History taking, physical exam, counselling) and focusing on terminal feedback instead (at the end of the task or encounter)(24)
• Recognizing that different levels of feedback require different timing and settings, and that some types of feedback may be best delivered in a private setting after a clinical encounter (ex. corrective or sensitive feedback, debriefing after a critical patient).(21,22)

Regarding the frequency of feedback, a few key solutions have been proposed to facilitate frequent feedback in the ED. Depending on the specific learning goals of the trainee and/or the clinical situation, this could either involve direct debriefing and feedback immediately after the clinical task, cumulative feedback delivered at the end of the shift, or both. Additionally, Buckley et al suggests a few solutions:

1. Encouraging ED physicians to clearly establish the expectation that frequent feedback will be provided throughout the shift
   • Does not need to be onerous, could be as simple as one thing done well and one thing to improve upon for the next patient or case
2. Implementing ‘feedback check-ins, similar to how we ‘run the list’ during a shift”(3)
   • This is especially important in the context of the ED, where often learners are scheduled to work with an attending only once and do not have the opportunity to form longitudinal feedback and coaching relationships. By providing learners with frequent points of feedback throughout the shift (as opposed to cumulative terminal shift feedback), this provides learners with the opportunity to implement changes on shift to be observed in real-time.
3. Clearly labelling the delivery of feedback, as some studies suggest discrepancies between resident and attending satisfaction with feedback volume, as sometimes residents may not recognize feedback is occurring.(25)

Feedback Process – Structure of delivery

Numerous feedback strategies exist, but no single approach is proven superior. The main feedback guidelines recommend avoiding a one-size-fits-all method, and instead tailoring feedback to the individual learner and clinical context.(9) While primarily suited to verbal feedback, these techniques can also guide written evaluations such as end-of-shift assessments or EPAs.

1. Sandwich Technique 

One of the earliest feedback structures is the “sandwich” technique, where corrective feedback is provided between two positive comments.(26) Its effectiveness has been debated in the literature. Critics argue it focuses on single encounters and positions feedback as an active process for the provider, but passive for the recipient.(25,27) Given the lack of discourse during the delivery of feedback, there is concern that an ‘over-emphasis on the positive aspects of performance can lead recipients to overlook corrective comments and to reach overly affirmative conclusions’.(28)

Two early RCTs examined the impact of this technique on learner performance.(28,29) While students receiving more praise reported higher satisfaction with the quality of feedback given, those given specific corrective feedback showed greater performance improvement. Rogers et al. noted this may be due to learners not prioritizing corrective elements within the sandwich structure, resulting in less accurate self-assessments given the imbalance in proportions between positive and corrective comments.(28,29) Given this mixed evidence, educators should recognize the limitations of the sandwich approach and consider evolving their feedback strategies accordingly.

2. Pendleton’s Feedback Rules

Another widely used feedback model is Pendleton’s Rules, proposed by Pendleton et al.(26,30) Unlike the sandwich method, this model promotes a learner-centered, interactive discussion.(26) It begins with the learner reflecting on what went well, followed by the assessor affirming those strengths. Next, the learner identifies areas for improvement, after which the assessor offers their own constructive feedback. The feedback conversation concludes with a summary of key takeaways.(31)

This method is particularly effective for fluency-based tasks—such as history taking, physical exams, and counseling—and can be used in both individual and group settings.(31) It encourages learner engagement, promotes reflection, and allows the assessor to highlight actionable teaching points while gaining insight into the learner’s thought process.(31) However, a key limitation is reduced feedback credibility when assessors merely echo the learner’s reflections without adding specific, individualized feedback. This can leave learners feeling responsible for identifying their own weaknesses without receiving concrete guidance(30,31). Overall, Pendleton’s model is a valuable foundation for feedback but should be complemented with other approaches.

Feedback Process main take-home points:

1. Ensure that trainee learning goals are clearly and specifically identified at the start of each shift along with an action plan of how these goals can be optimally observed to provide effective feedback.
2. Aim for frequent and timely feedback on shift – provide brief & specific points of feedback via feedback check-ins to allow learners to implement change.
3. Understand that there is no best way to structure feedback and ensure that feedback is an active conversation between the provider and receiver, rather than passive information sharing

Feedback Content

Increased feedback quantity does not equate to higher quality. A major issue cited within feedback-based literature is the lack of clarity and specificity in feedback, with up to 80% of comments rated as non-specific and 60% as ineffective(32,33).

Clarity is essential for learners to understand and apply feedback effectively.(34) Establishing learning goals early allows educators to tailor feedback to specific tasks. Feedback based on direct observation enhances credibility, learner acceptance, and clarity of action points.(35,36) When providing specific, corrective feedback, feedback providers are encouraged to specify whether the feedback is addressing essential improvements in performance, or it is based upon variations in practice pattern to enhance sufficient performance.(17) In the ED, direct observation doesn’t need to be burdensome—selective observation of specific encounters can still yield meaningful, specific feedback.(37)

Direct observation is most valuable for skills such as history taking, physical exam, communication skills, leadership skills and procedural skills, but certainly is not the most effective and efficient method for informing feedback on clinical reasoning and management.(38) These complex skills would benefit most from indirect observation, typically though discussion with the learner to gain insight: ask them why they decided to order a CT, or how they worked through a differential during a resus case. Despite the robust body of literature supporting direct observation and its impact on feedback credibility, there is little evidence to explore how learners perceive indirect observation-based feedback. A study conducted by O’Connell et al recently showed that residents tended to rate feedback from indirect observation to be less credible, however, only when residents were not aware of how indirect observation was used to inform the feedback provided to them.(39) Residents with more insight on the use and methods of indirect observation subsequently found the feedback to be more credible – and so it is important to ensure we sign post how our feedback is informed to increase credibility.  

Effective feedback balances corrective and encouraging elements, helping learners identify both strengths and areas for improvement.(9) In competency-based medical education (CBME), this allows learners to recognize achieved competencies and areas for further developmental.(40) Additionally, Sadler et al., states that “for information to become feedback, it must enable the learner to take action to remedy the gap between actual and desired performance.”(41) Without providing learners with actionable steps for improvement, it is unlikely that the feedback will motivate future learning and growth.(20,42,43) When possible, follow-up opportunities should be offered to demonstrate improved performance and reinforce feedback.(17)

Therefore, to summarize, the content of feedback should aim to be specifically geared towards:

1. Feedback should be clearly and specifically targeted toward learner goals. Aim to sign-post whether feedback is and based on directly or indirectly observed behaviors or encounters.
2. Learners should be provided with specific examples of how they excelled and areas for improvement, ensuring balance in feedback.
3. All constructive feedback should be followed by the creation of a tangible, specific, and actionable learning plan. When applicable, opportunities for follow-up and demonstration of improving performance should be provided.

Objective 3: Effects of language and implicit bias

As a final point, a common weakness of feedback within medical education is that even when providing specific feedback, it can often become person-oriented rather than task-oriented.(32) Person-oriented feedback is less effective and may threaten psychological safety, especially when addressing complex tasks or EPAs like critical care management, which involve both technical and interpersonal skills.(44) This is significant as residents place high value on feedback related to high-stakes EPAs, particularly resuscitation scenarios.(15)

Person-oriented feedback may stem from implicit biases rather than intentional behavior. At the workplace level, female emergency medicine residents disproportionately receive more negative, person-focused, and discordant feedback than male peers, in both written and verbal forms, and from both male and female evaluators. (45–47). While the topic of implicit gender biases is complex, a key component to these observed differences relates to the concept of ‘agentic’ and ‘communal’ traits – where women are stereotypically assumed to embody more ‘communal’ traits and often perceived negatively if embodying ‘agentic’ traits, which happen to be valued in critical care specialties such as EM.(48)

In the ED, gender stereotypes are often most visible during high-stakes resuscitations, influencing both the feedback learners receive and their own self-assessments—often shaped by internalized bias. Two recent studies show that many female residents feel discomfort displaying agentic leadership traits or worry they’re seen as less credible than male peers when being assertive. (49) Some also report increased stress when violating gender norms during codes, with a few even feeling compelled to apologize afterwards for counter normative behavior.(50)

Feedback providers should be mindful of gender bias when giving feedback on high-stakes resuscitations, and female-identifying learners should recognize how internalized stereotypes may shape self-perception. Feedback should focus on leadership effectiveness—not style or personality—as there’s no single “right” way to lead.(22,51)

Objective 4: Solicit and receive feedback; ‘feedback literacy’ 

No matter how well-delivered feedback is, its effectiveness depends on how the learner receives and applies it.(3,52) Stone and Heen classify key factors influencing feedback reception as: truth (credibility of the source), relationship (strength of the supervisory connection), and identity (the learner’s emotional response and psychological safety).(53) These three triggers, though not exhaustive, are widely cited as central to shaping feedback receptiveness.

Feedback Credibility

All previous recommendations on feedback delivery ultimately relate to how learners perceive the credibility of feedback and its source. Credibility is multifactorial and closely tied to psychological safety; without it, feedback loses its impact. Lefroy et al., states that “the credibility of feedback is influenced by the credibility of the source, by the processes by which the feedback was informed and created, and by the content and characteristics of the feedback itself.”(17,24)

A systematic review by Dai et al. supports this, showing that trainees perceive feedback as more credible when it is timely, reducing memory errors and enabling specific, relevant comments.(54–56) Feedback is also valued when aligned with learning goals and when learners contribute through self-assessment, reinforcing the need for clear, specific, and learner-centered feedback.(55–59)

When working to create actionable next steps with a trainee, it is important to assess their overall motivation and response to the feedback process so far.(17) Is the feedback questioning their current approach and creating defensiveness to knowing they need to change, or does it evoke a constructive emotional response which fosters motivation and belief in their ability to improve?(17) Natesan et al., proposes that, “failure to internalize feedback happens when a mismatch in external and internally generated assessment occurs,” which may typically arise from lack of clarity on behalf of the learner.(9) This highlights the need to shift feedback from a one-way exchange to a dialogue. Encouraging learners to ask clarifying questions strengthens credibility, deepens understanding, and supports alignment between feedback and self-perception.(52,53) 

Psychological Safety

Psychological safety is a major factor influencing feedback credibility—if learners don’t feel safe, they are less likely to engage meaningfully with feedback. Recent medical education literature has shifted toward viewing feedback as a coaching process, emphasizing collaboration, growth, and guided reflection over correction.(60) Our comments and observations can support learners in developing insight into their own strengths and weaknesses, build confidence, and enhance their future skills and learning.(60). Clearly stating this intent fosters an ‘educational alliance,’ where the feedback provider and learner work together to improve performance.(54) Building this alliance starts at the beginning of each shift, with the co-creation of learning goals. The feedback provider should emphasize that their role is to support the learner’s growth, encouraging active engagement throughout the shift. (9,52) Studies show that learners value feedback more when they feel supervisors genuinely care about their improvement.(55–57)

The degree of psychological safety affects how engaged a learner will be in feedback discussions. Johnson et al., states that, “the key question for any learner contemplating what to volunteer during a feedback conversation is: ‘what is the likelihood that I will be respected, accepted and assisted, or the opposite that I will be humiliated, reprimanded, or judged as inept?”.(61) To foster this, both the learner and provider must ensure the feedback process is a dialogue. Learners should feel safe enough to self-reflect, ask clarifying questions, and challenge feedback when appropriate, knowing it comes from a supportive place.

This process is difficult without a growth mindset. Creating an educational alliance aims to motivate learners to improve, accepting feedback as a tool for development rather than criticism.(62) It’s crucial to normalize mistakes and remind learners that feedback is about performance, not personal attacks.(1,53,63) Acknowledging and supporting self-reflection on mistakes strengthens the feedback process and encourages continuous growth.(61)

Feedback literacy and learner agency

Lastly, the concept of ‘feedback literacy’ is an important one in allowing the learner to feel empowered to take on an active role in feedback, as the onus does not fall only on the feedback provider to improve the quality of their feedback.(64) Learners equally have the ability to create psychological safety for the feedback provider, by initiating and engaging in feedback conversations, allowing the provider to recognize the learner is seeking out and willing to implement corrective feedback.(65) Feedback providers may often be hesitant about providing corrective feedback in fear of psychological harm.

Dr Elizabeth Molloy has been a key creator in the concept of feedback literacy, and her work defines this as, “the understandings, capacities, and dispositions needed to make sense of information and use it to enhance work or learning strategies,”.(66) If learners are not equipped with the correct skills to know how to effectively engage with feedback, the utility of the feedback is lost, as even the highest quality feedback will have no impact if the learner chooses not to engage with it. Essentially, feedback literacy enables the learner to reframe feedback as a process they could “initiate and engage in, rather than one they were subjected to”.(64) When learners know what they would like to gain from a feedback conversation, it enables them to ensure feedback conversations are useful and can generate meaningful plans for improvement, even if the provider of feedback is less feedback literate than the receiver.

In terms of soliciting feedback and using it to enhance our learning, the onus falls on us as learners to ensure that we maintain feedback continuity. For example – if we worked one shift where we asked for feedback on communication skills in a resuscitation setting but only had the opportunity to have this be observed once, we can then take the constructive feedback onto our next shift, by signposting to the next attending. As feedback providers, we can also ask learners if there is anything specific from a previous shift that the learner would like to implement.

Putting it all together: the ‘resistant’ learner 

Regardless of how well feedback is delivered, it is important to acknowledge and accept that trainees may not always be ready to perceive feedback as credible in the moment. However, this does not mean that it may not be eventually viewed as credible with time; sometimes learners may only see the value of your feedback when faced with a similar encounter down the road. When having feedback discussions with a learner who is not open to receiving corrective feedback, the process of creating an open and supportive dialogue can be especially important. If a learner has the courage to be honest in their own views, it is important to acknowledge this, as it can be tough to be vulnerable when you do not know someone very well. We should gently explore with the trainee where their reservations stem from in receiving this feedback and invite them to challenge our thoughts constructively and respectfully. We can also gently probe further about other feedback encounters:

• What did others recommend to them as areas of improvement?
• What did others state they felt the trainee did well?
• What does the trainee feel they excelled in, and what do they see as an area of improvement for themselves?

Difficult, corrective feedback

Similar themes apply to providing critical corrective feedback to a learner. Ensure you are in a private space with minimal distractions and can have a one-on-one conversation. Typically, immediate discussion is best for critical corrective feedback. Again, the importance of signposting a clear plan for where the discussion will go is important, so the receiver also has agency and understanding of what is to be discussed. Sign post that this conversation relates to corrective feedback and indicate the significance of the feedback – this typically would include stating that a critical mistake or error has occurred in the sense of patient safety, rather than a fault on the receiver. Finally, always ensure to generate a clear and feasible action plan to conclude in collaboration with the feedback receiver.

To summarize, here is an overall, succinct, evidence-based approach to effective, high-quality feedback in the ED:

Giving Feedback

1. Set up: discuss clear & specific trainee learning goals at the start of each shift and communicate a feedback action plan.
2. Process: aim for frequent and timely feedback on shift via feedback check ins to allow for change.
3. Content: ensure feedback is clear, specific, task-oriented, balanced, and actionable & signpost to feedback receivers how your feedback was informed.

Receiving Feedback

1. Feel empowered to improve your feedback literacy and solicit effective feedback.
2. Emphasize the importance of psychological safety for both parties, and signpost this during discussions when appropriate.
3. Use the strategies in giving effective feedback to foster a strong educational alliance.
4. When receiving feedback you may not agree with, identify the emotional reaction and decipher how this reaction may be impacting your receptiveness to the feedback content.