Feedback is an essential part of education and training programmes. It helps learners to maximise their potential at different stages of training, raise their awareness of strengths and areas for improvement, and identify actions to be taken to improve performance.
Feedback can be seen as informal (for example in day-to-day encounters between teachers and students or trainees, between peers or between colleagues) or formal (for example as part of written or clinical assessment). However, ‘there is no sharp dividing line between assessment and teaching in the area of giving feedback on learning’ (Ramsden, 1992, p. 193). Feedback is part of the overall dialogue or interaction between teacher and learner, not a one-way communication.
If we don't give feedback what is the learner gaining, or indeed, assuming?
They may think that everything is OK and that there are no areas for improvement. Learners value feedback, especially when it is given by someone credible who they respect as a role model or for their knowledge, attitudes or clinical competence. Failing to give feedback sends a non-verbal communication in itself and can lead to mixed messages and false assessment by the learner of their own abilities, as well as a lack of trust in the teacher or clinician.
Most clinicians already give feedback to students or trainees. This module offers some suggestions on how you can improve the feedback you give so that you are better able to help motivate and develop learners’ knowledge, skills and behaviours.
Feedback is important to the ongoing development of learners in healthcare settings. Many clinical situations involve the integration of knowledge, skills and behaviours in complex and often stressful environments with time and service pressures on both teacher and learner. Feedback is central to developing learners' competence and confidence at all stages of their medical careers.
Over the past few years, new assessment procedures have been introduced for junior doctors. Clinical practice and professional behaviours and attitudes are regularly and routinely assessed using a raft of workplace-based assessments. Such tools may include multi-source feedback, observations of clinical performance and case-based discussions. Feedback is a critical element of all these assessments and will involve health professionals across the board in their delivery, on multiple occasions and throughout the training programme.
Jill Gordon (writing in 2003 about the importance and influence of one-to-one teaching situations in clinical medicine) reinforces this, noting that feedback is vital and that the most effective and helpful feedback is based on observable behaviours:
Learners value feedback highly, and valid feedback is based on observation. Deal with observable behaviours and be practical, timely, and concrete. The one to one relationship enables you to give feedback with sensitivity and in private. Begin by asking the learner to tell you what he or she feels confident of having done well and what he or she would like to improve. Follow up with your own observations of what was done well (be specific), and then outline one or two points that could help the student to improve. (p. 544)
She goes on to note that one of the main purposes of feedback is to encourage reflection:
Just as many learning opportunities are wasted if they are not accompanied by feedback from an observer, so too are they wasted if the learner cannot reflect honestly on his or her performance. One to one teaching is ideally suited to encouraging reflective practice, because you can model the way a reflective practitioner behaves. Two key skills are (a) ‘unpacking’ your clinical reasoning and decision making processes and (b) describing and discussing the ethical values and beliefs that guide you in patient care. (p. 544)
Grounding feedback within an overall approach that emphasises ongoing reflective practice helps learners to develop the capacity to critically evaluate their own and others’ performance, to self-monitor and move towards professional autonomy.

Who gives feedback?

  • Teachers
  • Parents
  • Peers and colleagues
  • The learner themselves
  • Others

Linking feedback to the learning process:

It is very important to ensure that the feedback given to the learner is aligned with the overall learning outcomes of the programme, teaching session or clinical activity in which the learner is engaged. Giving feedback can be seen as part of experiential learning. Kolb (1984) proposed that learning happens in a circular fashion, that learning is experiential (learning by doing), and that ideas are formed and modified through experiences. These ideas underpin the idea of the ‘reflective practitioner’ and the shift from ‘novice to expert’ which occurs as part of professional development.
The learning cycle requires four kinds of abilities or learning contexts:
  • concrete experience – learners are enabled and encouraged to become involved in new experiences
  • reflective observation – gives learners time to reflect on their learning
  • abstract conceptualisation – learners must be able to form and process ideas and integrate them into logical theories
  • active experimentation – learners need to be able to use theories to solve problems and test theories in new situations.

Giving informal feedback: maximising opportunities:

There are many opportunities for giving informal feedback to learners on a day-to-day basis. Spencer’s article ‘Learning and teaching in the clinical environment’ (2003) describes a range of aspects and activities concerned with helping clinical teachers to optimise teaching and learning opportunities that arise in daily practice, such as planning, using appropriate questioning techniques and teaching in different clinical contexts. Such techniques often involve giving feedback to learners on their performance or understanding, but the feedback is built into everyday practice. Those giving feedback can help the learner to move through the stages in the ‘competency model’ of supervision (Proctor, 2001; Hill, 2007) as shown in the table below.

Low level of competence. Unaware of failings
Low level of competence. Aware of failings but not having full skills to correct them
Demonstrates competence but skills not fully internalised or integrated. Has to think about activities
Carries out tasks with conscious thought. Skills internalised and routine.
Little or no conscious awareness of detailed processes involved in activities
Helps learner to recognise weaknesses, identify areas for development and become conscious of incompetence
Helps learner to develop and refine skills, reinforces good practice and competence, demonstrates skills
Helps learner to develop and refine skills, reinforces good practice and competence through positive regular feedback
Raises awareness of detail and unpacks processes for more advanced learning, notes any areas of weakness/bad habit

Hesketh and Laidlaw (2003) note that providing informal on-the-job feedback can take only a few minutes of the clinician’s time. To be the most effective, feedback should take place at the time of the activity or as soon as possible after so that the learner (and teacher) can remember the events accurately. The feedback should be positive and specific, focusing on the trainee’s strengths and helping to reinforce desirable behaviour: ‘You maintained eye contact with Mrs X during the consultation, I feel this helped to reassure her…’.

Negative feedback should also be specific and non-judgemental, possibly offering a suggestion: ‘Have you thought of approaching the patient in such a way…’. Focus on some of the positive aspects before the areas for improvement: ‘You picked up most of the key points in the history, including X and Y, but you did not ask about Z…’. Avoid giving negative feedback in front of other people, especially patients.

Keep the dialogue moving with open-ended questions: ‘How do you think that went?’, which can be followed up with more probing questions. Hesketh and Laidlaw (2003) also suggest that learners should be encouraged to ‘seek feedback themselves from others… feedback actually works best when it is sought’.

Giving formal feedback:

Observations over a period of time or for specific purposes (e.g. appraisal, end of attachment interviews) are typical situations when formal feedback occurs in the clinical setting. Teachers may also be required to participate in formal clinical and non-clinical assessments which ideally should incorporate feedback to the learner.
If ongoing feedback has been carried out regularly, then the formal feedback sessions should not contain any surprises for the learners. Feedback can be given on a one-to-one basis or in small groups. The structure for giving feedback will be agreed between you and the learner(s), and may follow one of the models described above. It is also important that both you and the people to whom you are giving feedback are fully prepared for the session.

Prior to a formal feedback session you should:

  • ensure the learner is aware they are to receive feedback (so clearly define the purpose of the feedback session prior to or at the outset of the session)
  • collect any information you need from other people
  • summarise the feedback and ensure you know the positive aspects and areas for improvement are listed (with supporting evidence)
  • make sure you know how the feedback relates to the learning programme and defined outcomes.

Setting the scene:

  • create an appropriate environment
  • clarify your ground rules with the students – what part of the history or examination the student is to concentrate on, when you will interrupt, what other students are to do, how the student can seek help during the consultation, etc.
  • agree a teaching focus with the student
  • gain the patient’s consent and co-operation
  • make notes of specific points.

During the formal feedback session, you should:

  • redefine the purpose and duration of the feedback session
  • clarify the structure of the session
  • encourage the learner to self-assess their performance prior to giving feedback
  • aim to encourage a dialogue and rapport with the trainee
  • reinforce good practice with specific examples
  • identify, analyse and explore potential solutions for poor performance or deficits in practice.

After the session, you should:

  • complete any outstanding documentation and ensure the learner has copies
  • carry out any agreed follow-up activities or actions
  • make sure that opportunities for remedial work or additional learning are arranged
  • set a date for the next feedback session, if required.

Receiving feedback:

Sometimes feedback is not received positively by learners, and fear of this can inhibit teachers giving regular face-to-face feedback. People’s responses to criticism, however constructively it is framed, can vary. Learners often discount their ability to take responsibility for their learning, and their responses may present in negative ways, including anger, denial, blaming or rationalisation (King, 1999). When giving feedback, it is helpful to maintain an empathic yet consistent approach with a view to helping the learner take responsibility for development and improvement.
The focus in this module has mainly been about giving effective feedback to learners, but it is also helpful to think in a structured way about how feedback might be received. You can help to prepare learners (and yourself) for receiving feedback by providing opportunities for them to practise the guidelines listed below.
The aim of developing an open dialogue between the person giving feedback and the recipient is so that both parties are relaxed and able to focus on actively listening, engaging with the learning points and messages, and developing these into action points for future development.

Guidelines for receiving constructive feedback

  1. Listen to it (rather than prepare your response/defence).
  2. Ask for it to be repeated if you did not hear it clearly.
  3. Assume it is constructive until proven otherwise; then consider and use those elements that are constructive.
  4. Pause and think before responding.
  5. Ask for clarification and examples if statements are unclear or unsupported.
  6. Accept it positively (for consideration) rather than dismissively (for self-protection).
  7. Ask for suggestions of ways you might modify or change your behaviour.
  8. Respect and thank the person giving feedback.


Young students will often look up to instructors as experts in the field and take to heart most of the things instructors say. Thus, it is believed that spending a fair amount of time and effort thinking about how to respond to students may be a worthwhile time investment. Sometimes the term "feedback" is used loosely or carelessly to refer to what is more accurately called reinforcement. Here are some general types of reinforcement that can be used in many types of student assessment:
Your answer was incorrect.
Your answer was incorrect. The correct answer was Jefferson.
Your answer was incorrect because Carter was from Georgia; only Jefferson called Virginia home.
Your answer was incorrect. Your choice of Carter suggests some extra instruction on the home states of past presidents might be helpful.
Your answer, Jefferson, was correct. The University of Virginia, a campus rich with Jeffersonian architecture and writings, is sometimes referred to as Thomas Jefferson’s school.

Providing Assessment and Feedback

Assessing learning and providing feedback can be challenging in any pedagogical environment. In the context of the case method, these challenges are compounded by the importance of participation and the shared responsibility of instructors and students in the co-creation of content and process. The next sections examine approaches for judging the success of case method classes and assessing student and instructor performance.
  • Judging sucess
  • Student performance
  • Instructor performance

Judging sucess

Judging success within the context of the case method can be challenging given the breadth of learning objectives, including knowledge transfer, skills development, and the cultivation of self-awareness, judgment, and the capacity to lead. In the short run, the success of an individual case session can be assessed with respect to the specific objectives pursued for that class. In terms of content, did students demonstrate appropriate progress in the substantive discovery and learning envisioned for the class session? In terms of process, was there a healthy balance between instructor guidance and student initiative? These and other measures of success are described in more detail in "Characteristics of Effective Case Teaching" and "In-Class Assessment of Discussion-Based Teaching".

Student Performance

Student performance in a case method course may be assessed along a variety of dimensions including class participation, individual written work on papers and exams, and group activities such as projects and presentations. Our focus here is on class participation, which is integral to the case method and often accounts for a significant portion of a student's grade (typically 50% at HBS—)Experienced case instructors evaluate class participation based on a student's contribution to the collective learning during class discussions. Establishing objective assessments of these contributions can be challenging. The quality of individual contributions relates not only to the content, but also the delivery and timing of comments within the flow of the class discussion. More frequent participation is often a positive factor, although excessive attempts to comment may lead to lower quality contributions and may reflect a bias toward speaking over listening. In assessing participation, instructors should be aware of the critical role they play in shaping student performance through calling patterns and the types of questions and follow-ups they use with individual students. Also, the quality of the instructor's participation tracking system may significantly affect the reliability of the overall performance evaluation.

Instructor Performance

The discussion provided under Judging Success provides a useful starting point for assessing the performance of a case method instructor. Much of the instructor's impact on student learning takes place in the classroom. Although students bear co-responsibility for their learning, the instructor's effectiveness in motivating and guiding participants is often a critical determinant of success. Ironically, the case instructor's performance in the classroom often depends significantly on activities outside the classroom, including pre-class preparation and external interactions with students via office hours, e-mail, and other means.
Instructors can draw on multiple sources of feedback to assess their performance and receive developmental input. Feedback may come from students, in the form of non-verbal signals and direct comments, mid-course surveys, and end-of the-term student evaluations. Useful feedback may also come from class observations by faculty colleagues and from teaching and learning specialists.