Anyone who has ever taken driving lessons probably recalls the importance of feedback from the instructor. Without corrective suggestions from an experienced adviser sitting in the passenger seat, learning to drive would be a complicated and dangerous endeavor. The same is true for teaching someone how to become a doctor. For centuries, physicians have been trained under closely supervised apprenticeships, whereby mistakes and misdirected approaches are detected and corrected early, if possible, before any serious consequences occur. Physicians-in-training and drivers-in-training, alike, must be told both what they are doing correctly and incorrectly, in order to become safe, competent and independent practitioners.

Despite the intuitive importance of performance feedback, both the medical education literature and personal experience suggest that medical educators are often neglecting to provide effective performance feedback to physicians-in-training. Ask a psychiatrist if she provides performance feedback to students, and she might reply, “Sure, it is important. I do it all the time.” Ask a resident for her opinion on performance feedback, and you may hear, “I rarely receive feedback myself, but I always tell the med students how they are doing.” Ask a medical student if he receives feedback on his performance and he may say, “No one says very much … and when they do, it does not really help me.” How is it that the perceptions held by the psychiatrist, the resident, and the medical student are so strikingly different?

The authors looked to the literature for answers—and found very little on performance feedback in undergraduate psychiatric education. Instead, the authors found descriptions of performance feedback difficulties encountered by various specialties at all levels of medical training. Although the literature describes the problems with feedback delivery, it has less to say about the reasons for these problems. There are various articles on how to improve feedback delivery (1–4), but no articles to explain why the authors need this advice in the first place. Why do physicians struggle with performance feedback for medical students?

Written by a medical student, psychiatry resident, and psychiatrist, this article fills a void in the psychiatric education literature by providing a review of 1) the challenges that both medical students and psychiatry preceptors face regarding performance feedback and 2) areas where research is needed to overcome these challenges. The purpose of the article is to stimulate thought and discussion on the question of why medical students, residents, and psychiatrists struggle with performance feedback conversations. An understanding of the barriers to constructive performance feedback delivery may lead to more effective use of the feedback strategies and techniques that are currently being promoted in the literature.

Since the first article specific to performance feedback in undergraduate psychiatric education appeared only recently (5), perhaps an important barrier to feedback delivery relates to a lack of awareness by preceptors. Several articles have described the impact of performance feedback on trainees in other areas of medicine. There is evidence that performance feedback leads to improved diagnostic skills (6), lower operating room costs (7), more appropriate use of lab tests (8) and better quality medical charting (9). Not only is such feedback important, but it is desired by trainees. A 2002 survey of 312 medical students found that 95% of respondents agreed that feedback provision was an important means of ensuring competence and guiding learning, and “a large number of respondents expressed a desire for the provision of more feedback on performance” (10).

Another reason that physicians neglect their performance feedback responsibilities may be that they do not appreciate the extent of these responsibilities. In accordance with the “Functions and Structures of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree” (11), medical schools must provide students with formative evaluation (under which performance feedback falls). Similar requirements have been created for accreditation of postgraduate residency programs by the Royal College of Physicians and Surgeons of Canada (12, 13). It seems unlikely that the average psychiatrist who supervises medical students has read the accreditation documents (there appear to be no studies that measure preceptor familiarity with accreditation requirements). Preceptors who are unaware that performance feedback is important for program accreditation may not devote the deserved amount of time or energy to this endeavor in the clinical setting. Psychiatrist awareness of the importance and need for performance feedback is a potential problem that warrants further study.

A challenge facing educators in psychiatry is performance feedback delivery that is useful for the medical student. There tend to be discrepancies in the way trainees and preceptors perceive feedback (14). The best-intended feedback may be unhelpful if it is: 1) not descriptive or specific enough 2) not “age-appropriate” and 3) mistaken for evaluation.

Several articles have noted deficiencies in the quality of the feedback delivered in undergraduate medical education. Undergraduate psychiatry students have expressed a need for more constructive criticism and structured feedback and seemed to appreciate comments on areas for personal improvement (5). A content analysis of the final assessment of medical student performance on a pediatrics rotation found that specific comments on student skills tended to be lacking (15). In another study, despite efforts to enhance feedback, only 10% of the preceptor comments were rated by the students in a surgical clerkship as “helpful” (16). A content analysis of the subjective comments made by faculty and senior residents on junior resident evaluations on an inpatient family medicine service found that “most comments were generic, and do not help inform learning,” with only 14% of comments specifically targeting competence and skill (17).

One of the subtle performance feedback challenges relates to offering suggestions that are appropriate to the level of training. In a given day, a psychiatrist may encounter trainees at various skill levels. A junior medical student requires different guidance compared to a senior fellow, and failure on the part of the supervisor to tailor feedback to the needs of the trainee will render the feedback less useful. Trainees have been shown to value feedback comments that are specific to the learner’s performance (18). As well, junior residents, more than senior residents, have been shown to value performance feedback, perhaps because junior residents, similar to medical students, rely upon feedback to develop skill sets (19). Furthermore, the psychiatrist who forgets that the medical student is at a basic level of training risks mistaking performance feedback for evaluation. Performance feedback should move a student toward a learning objective and guide future learning, whereas performance evaluation should determine how successfully the student has met the learning objective (1–4). The participants in the Moorehead et al. study (18) appeared to value performance feedback over nonspecific evaluative feedback. The ability of the psychiatrist to understand the performance feedback needs specific to the medical student requires further study.

The literature suggests that both faculty and residents desire training on performance feedback delivery to medical students. In one study, 39% of preceptors wanted training around feedback delivery, and 38% wanted training on how to evaluate medical students (20). In another study, faculty expressed appreciation for a feedback-training workshop, designed to improve faculty confidence skill and comfort when teaching pediatric topics to medical students (21). As well, resident preceptors have been shown to require training in identifying the learning needs of medical students on a surgical rotation (22). Perhaps it is lack of training (fear of doing it wrong, hurting the student’s feelings, not knowing how to say it) on the part of psychiatric preceptors that hinders effective performance feedback to medical students. At present, no studies exist to prove or disprove this hypothesis.

One significant barrier to performance feedback delivery in psychiatric education may be the erroneous belief among clinicians that feedback delivery skills are innate. The lack of literature examining performance feedback in psychiatric education may be indirect evidence of the belief that there is no reason to evaluate or improve feedback skills. Since constructive feedback has been defined as “the art of having a conversation with learners about their performance” (23, p. 109), psychiatrists may assume that their ability to conduct therapeutic interviews with patients is equivalent to the performance feedback conversation with medical students. Indeed, there are similarities between a physician who works with the patient to identify the problem and related treatment plan and a preceptor who identifies student weaknesses and related learning plan. Several feedback methods promoted in the education literature use techniques that should be entirely familiar to the psychiatrist who speaks with patients regarding diagnosis and treatment. For example, the Standing Committee on Postgraduate Medical Education of England (SCOPME) model (23, p. 110) advises preceptors to “support, counsel and inform without censuring” when giving performance feedback. The Chicago model (23) advises giving feedback focused on behavior, rather than personality (in much the same way that a physician tells a patient she has a disease, not that she is a disease). The Six-Step Problem Solving Model (23) of feedback delivery is very similar to the work of the clinician: in this model, the problem is presented, discussed and agreed upon, and the solution is proposed, discussed and agreed upon.

It seems that any physician who diagnoses and treats patients should be able to offer the equivalent performance appraisal and learning plan to trainees. However, as described in other sections of this article, physicians tend to provide only vague appraisals (diagnosis) of trainee performance, leaving students without any clear sense of a learning plan (treatment). It appears that physician behavior can be modified using interventions and training sessions to improve performance feedback delivery (15, 16, 24–32). The onus, however, is on physicians to accept that performance feedback delivery training is necessary and applicable. The current literature reveals no answers as to what prevents preceptors from either fully using skills they already have or developing skills they presently lack. Psychiatrist comfort and familiarity with performance feedback delivery require further study.

Although articles exist on efforts to encourage preceptors to provide, and medical students to solicit (16, 41) performance feedback, little is known about how medical students or preceptors manage critical feedback. It has been shown that physicians tend to inflate a surgical clerk’s grade if required to deliver the result to the student face-to-face rather than in writing (33). As well, when several high profile medical schools replaced the traditional letter grades with the pass-fail system, reports appeared in the popular press about the need to quell competition among medical students (40). Although performance feedback and pass-fail evaluation are entirely different entities, perhaps these concepts have blurred, leading psychiatrists to hesitate when delivering feedback to medical students (for fear of promoting unhealthy competition among colleagues). More likely, psychiatrists who fear the worst about the consequences of performance feedback (the student may sue the physician; the student, a future colleague, may have hurt feelings or hold a grudge; the student may lose out on a competitive residency) may temper their comments, or exaggerate student success, rather than deal with the result of critical constructive feedback. Perhaps medical students, accustomed to high premedical school grades but little in the way of performance feedback, are not equipped to tolerate critical constructive feedback. Psychiatrist and trainee management of critical feedback is an interesting area that warrants further study.

Perhaps psychiatry preceptors struggle when delivering performance feedback to medical students due to lessons learned from the hidden curriculum. The “hidden curriculum” refers to the “set of influences that function at the level of the organization structure and culture, including, for example, implicit rules to survive the institution, such as customs, rituals and taken-for-granted aspects” (34). Several lessons from the hidden curriculum in medical education can be considered barriers to effective performance feedback delivery. For example, anyone who has ever received or delivered humiliating or sarcastic feedback, and accepted it as a “rite of passage”, is familiar with the hidden curriculum of a rotation. First-person descriptions of experiences with humiliating feedback have been written from the perspective of the medical trainee (35, 36), and the demotivating effects of deconstructive feedback on junior trainees have been described (37). In the Rotenberg et al. study (22), surgical residents noted that they rarely received feedback from surgeons on how well they were teaching medical students. Residents who are not taught how to teach, but learn poor examples from faculty preceptors, will perpetuate ineffective teaching habits and techniques. At the bottom of the educational hierarchy is the medical student, who bears the effects of deconstructive feedback.

Another example of a hidden curriculum lesson can be heard from psychiatrists who say they are too busy to provide feedback to medical students. Trainees who realize that preceptors are “too busy” to give feedback inadvertently learn that feedback is not important enough to warrant a moment of time during the day. This is a lesson that medical students will carry into residency and “consultanthood,” which will further propagate barriers to feedback delivery in psychiatric education. Contrary to what may be popular belief among busy clinicians, effective strategies can be employed to ensure that a busy ambulatory setting is also a very good climate for giving and receiving feedback (25). In fact, clinical productivity of preceptors may not differ for sessions with, and without, a student in the context of urban community health centers (38).

A third example of hidden curriculum influence on performance feedback delivery is the concept of the medical trainee as the “adult learner.” Preceptors may mistakenly assume that adult learners do not need performance feedback. In fact, professional coaching and mentoring (under which is included performance feedback) are required for adult learners to achieve their educational goals. As Speck (42, p36–37) notes, “Transfer of learning for adults is not automatic and must be facilitated. Coaching and other kinds of follow-up support are needed to help adult learners transfer learning into daily practice so that it is sustained.” Mentoring relationships have been shown to improve the academic success of junior faculty (39) and should be taken as evidence that fully qualified academic physicians both benefit from and require professional guidance and feedback in order to remain on-track for their professional goals. The same must be said of adult learners in medical school. The impact of the hidden curriculum on performance feedback delivery to the medical student by the psychiatrist and resident is a complex area that is in need of further study.

There is a void in the literature regarding the provision of performance feedback in clinical undergraduate psychiatry training. While our counterparts in other areas of medicine have begun to explore strategies to enhance and facilitate performance feedback delivery, it appears that clinical educators in psychiatry have been mostly silent. Furthermore, while the medical education feedback literature focuses on how to improve feedback techniques, the literature offers no answers as to why the problems with performance feedback delivery exist in the first place. The authors suggest that efforts need to be directed toward answering a very important question: Why are clinical preceptors not meeting the feedback needs of medical students? The educational value of performance feedback is known. The feedback models, strategies and tips exist. So, where does the problem truly lie? The authors suspect that solutions to the feedback problem will arise not out of new or refined strategies, but through a better understanding of the barriers and challenges that psychiatrists, residents and medical students face during feedback conversations.