Education for Health

: 2021  |  Volume : 34  |  Issue : 3  |  Page : 96--100

Strengthening the feedback culture in a postgraduate residency program

Muhammad Tariq1, Jack Boulet2, Afaq Motiwala3, Sana Saeed1, Safia Awan4, Tabassum Zehra1, Syeda Kausar Ali5,  
1 Department for Educational Development, Aga Khan University, Karachi, Pakistan
2 Medical Council of Canada, Ottawa, ON, Canada
3 Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
4 Department of Medicine, The Aga Khan University, Karachi, Pakistan
5 Department of Medical Education, Jinnah Sindh Medical University, Karachi, Pakistan

Correspondence Address:
Muhammad Tariq
Department for Educational Development, Aga Khan University, Karachi


Background: Feedback is defined as specific information presented to a learner that facilitates professional development through the process of reflection. Timely provision of constructive feedback to learner is important in optimizing the learning curve. The aim of the current study was to see the effectiveness of various interventions on feedback practices of faculty members. Methods: This is a quasi-experimental study (pre- and postdesign). It was conducted from November 2009 to March 2011 at The Aga Khan University, Pakistan. Faculty development workshops, allotment of specified feedback time, and restructuring of residency feedback forms were done as interventions. Data collection was done pre- and postintervention. Resident's and faculty satisfaction regarding the feedback process were evaluated using a prepiloted questionnaire. Paired t-test was applied to assess the effect of interventions on faculty and resident's satisfaction. Results: The mean satisfaction scores of residents were significantly improved (P < 0.05). Pre- and postintervention faculty satisfaction score also demonstrated significant difference in overall satisfaction level, from 47.88 ± 13.92 to 63.40 ± 8.72 (P < 0.05). Discussion: This study showed improved faculty engagement and satisfaction for the provision of feedback to the trainee resident. Strengthening this, culture requires continuous reinforcement, individualized feedback to the faculty members regarding their feedback practices, and continuing faculty development initiatives.

How to cite this article:
Tariq M, Boulet J, Motiwala A, Saeed S, Awan S, Zehra T, Ali SK. Strengthening the feedback culture in a postgraduate residency program.Educ Health 2021;34:96-100

How to cite this URL:
Tariq M, Boulet J, Motiwala A, Saeed S, Awan S, Zehra T, Ali SK. Strengthening the feedback culture in a postgraduate residency program. Educ Health [serial online] 2021 [cited 2022 Jul 5 ];34:96-100
Available from:

Full Text


Formative assessment plays an important role in postgraduate training. Formative assessment promotes learning by incorporating constructive feedback.[1] It allows training supervisors to identify the learning needs of learners and develop plans to respond to those needs through effective feedback.[2],[3] Feedback is defined as specific information presented to a learner to promote reflection on performance with the ultimate goal is to helping learners in establishing their own goals and critiquing their own performance.[2] Effective feedback emphasizes learner self-assessment, behavior change, and professional growth.[4] Academic institutes have been increasingly working to reinforce the culture of feedback provision. Feedback culture refers to the organization's support for feedback, including nonthreatening, behaviorally focused feedback, coaching to help learners interpret, and use feedback, and a strong link between performance improvement and valued outcomes.[5]

Verbal feedback is the use of verbal communication to close the gap between what is known and what is still to be learnt.[6] The regular practice of giving constructive and focused verbal feedback improves performance as it serves to guide future learning, nurtures habits of self-reflection and self-remediation, and promotes access to advanced training.[7],[8]

The literature has stressed that providing timely feedback to the learner is important, although trainers/facilitators have reported that the process is difficult and time-consuming.[9] An interesting gap reported in the literature was that the medical student and residents felt that they did not receive effective feedback, whereas the faculty perceived that the feedback which is provided may be underrecognized.[10] This may reflect inadequacies of the supervisors communicating the feedback or the inabilities of residents to receive and/or respond appropriately to feedback.[11] Effective feedback should be based on direct observations provided it is specific and focused.[12] Numerous interventions (e.g., seminars, webinars, etc.) have been utilized specifically to address upon this area to improve methods and comfort in giving both positive and negative feedback.[2] The organization role for promoting feedback culture has a pivotal importance in harmonizing this process.[4]

Most of the learning in postgraduate training occurs through workplace teaching and learning.[13] Residents and their supervisors agree that feedback is a crucial component of this process.[9] Feedback enables the residents to learn the process of developing self-assessment skills which serve them throughout their professional lives.[14] Self-assessment alone is unreliable, and feedback from external sources is essential to confirm or disconfirm self-perceptions.[15]

The Aga Khan University Hospital in Karachi (AKUH), Pakistan, is a not-for-profit private medical university. It has a 4-year structured residency program in internal medicine. Residents in internal medicine have reported the verbal feedback component to be inefficient and ineffective in their training. Internal medicine residents rotate through different specialties with assigned faculty for specified periods of time during the 4 years of residency training. Attending physicians supervise and evaluate resident performance using a structured evaluation form, which is then submitted to Residency Program Director. The compiled evaluations of the academic year are shared with the residents at year-end. This results in loss of opportunity for ongoing learning and thereby detracts the importance of in-time verbal feedback.


The aim of this study is to evaluate the effectiveness of faculty development on the provision of structured verbal feedback and its influence on resident's performance and satisfaction of both faculty and the residents with the process of verbal feedback.


This study was conducted in the Department of Medicine at The AKUH, Pakistan, from November 2009 to December 2011. This project was funded by the University Research Council (Project ID No. 091013-MED). Ethical approval was granted from the Ethical Review Committee of the University. Written informed consent was obtained from all study participants.

Study design

This was a quasi-experimental study with a pre- and postdesign using an intervention. Internal medicine residents voluntarily consented to participate in this study (n = 49, year = I, II, III, and IV). Faculty members who are residency training supervisors were invited and participated. The co-investigators were not allowed to take part in the study.

Pre- and postintervention data collection

Feedback activity survey

The survey instrument was developed using the tailored design method and reviewed by a group of clinicians–educators with experience in instrument development. It consisted of 12 items which rated frequency of feedback activities on a seven-point Likert's scale (1 = at no time or never, 4 = 50% of the times, and 7 = always).

The instruments were piloted, and changes were incorporated before final usage.


Faculty development workshops on providing feedback

Faculty was trained on providing effective feedback to residents. These workshops were held between January and March 2010. Five workshops were conducted with an average of 9–11 participants in each workshop. All workshops were conducted by the same facilitators including one clinician and two medical educationists. The duration of the workshop was 3 h. More than 90% of the departmental faculty members attended the workshops. Various challenges were identified and sorted out during these workshops.[16] The key strategies which were utilized during these workshops were facilitator-led discussions and role-play

Implementation of revised resident's evaluation form

Based on the faculty and resident feedback, the rotation evaluation form was revised and implemented in March 2010.

Time allocation for feedback

The issue of time constraint was addressed by providing a 1-h free slot on each Friday to individual faculty for the purpose of providing feedback.

Statistical analysis

The main purpose of the statistical analysis was to see the level of faculty and resident's satisfaction and improvement in resident's performance, pre- and postintervention. Paired t-test was used to see the association between pre- and posttest variables to compare the resident's and faculty satisfaction and performance, respectively. Statistical Package for the Social Sciences version 19 was used for analysis. All P values were two-sided and considered statistically significant if < 0.05.


Pre- and postintervention feedback activities: Resident ratings

The overall mean score was improved from 24.28 ± 13.90 to postintervention 44.04 ± 21.03 and this was statistically significant (P < 0.05). Pre- and postactivity ratings were found to be statistically significant on 11 out of 12 items individually also (P < 0.05). No significant difference was observed for the provision of feedback in a timely manner [Table 1].{Table 1}

Pre- and postintervention feedback activities: Faculty ratings

The total score (mean of all items) was significantly improved from 47.88 ± 13.92 to 63.40 ± 8.72, and P value of 0.001 [Table 2].{Table 2}


Feedback is a vital and integral constituent of medical teaching which facilitates in enhancing and at the same time encouraging the learners to refine their knowledge, skills, and professional performance.[16]

In this study, we provided platform to the key stakeholder for refining the process of verbal feedback including faculty members, medical educationists, and resident representatives. The core purposes were to develop a common understanding about the vitality of in time effective verbal feedback, to provide faculty development to ensure the provision of effective verbal feedback, and to refine the key strategies which impact the feedback process.[17] The latter included modification of the evaluation form and providing the protected time to the faculty members for timely interaction with the residents. The effect of timely feedback has been reported in other studies.[6],[18]

This study demonstrated the improvement in the overall feedback process as reported by the activity survey by faculty members and the residents. The residents reported an increase in the nonjudgmental feedback provided by the faculty members during the verbal feedback. Schultz et al. also reported student perceptive about attributes of preceptor that maximizes their learning that included preceptors who give timely and effective feedback.[18] The importance of nonjudgmental approach for providing feedback has been reported in many studies. Schartel[19] emphasized the quality of nonjudgmental feedback approach in his study and found that removing adjectives (good, bad, etc.) from the feedback leads to clear and effective communication of actionable tasks to the learners. Faculty members learnt how to ensure self-reflection by residents about their performance and how to direct them to work on their weaknesses. Branch et al.[20] also reported positive impact of reflection on learning and using of feedback effectively by the learner.

There are certain limitations to the study which includes; although most of the faculty members participated in the workshop, fewer of them actually participated in both pre- and postintervention component of the study which could contribute to a certain bias. The postintervention improvement in the perceived effectiveness of feedback by faculty and residents could be due to the exposure of feedback activities on the pretest. The use of multimodal assessment strategies to ascertain the impact of feedback on resident's performance and longitudinal follow-up with faculty and residents to determine the effectiveness of feedback training may be areas of focus in future research.


Feedback facilitates in encouraging the learners to improve their knowledge, attitude, and skills. It is a two-way process which requires expertise at the end of feedback provider as well as receiver. This study demonstrated improvement in the overall feedback process using various strategies. Such activities need to be regularly planned for faculty development in areas which are underestimated yet are pivotal to enhance the feedback culture in training programs.

Financial support and sponsorship

University Research Council (Project ID No. 091013-MED).

Conflicts of interest

There are no conflicts of interest.


1Tariq M, Boulet J, Motiwala A, Sajjad N, Ali SK. A 360-degree evaluation of the communication and interpersonal skills of medicine resident physicians in Pakistan. Educ Health (Abingdon) 2014;27:269-76.
2Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach 2005;27:470-2.
3Aboulsoud SH. Formative versus summative assessment. Educ Health (Abingdon) 2011;24:651.
4Kraut A, Yarris LM, Sargeant J. Feedback: Cultivating a positive culture. J Grad Med Educ 2015;7:262-4.
5Kerr K, Romaniuk M, McLeay S, Khoo A, Dent MT, Boshen M. Increased risk of attempted suicide in Australian veterans is associated with total and permanent incapacitation, unemployment and posttraumatic stress disorder severity. Aust N Z J Psychiatry 2018;52:552-60.
6Porte MC, Xeroulis G, Reznick RK, Dubrowski A. Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. Am J Surg 2007;193:105-10.
7Farrand P, Perry J, Linsley S. Enhancing Self-Practice/Self-Reflection (SP/SR) approach to cognitive behaviour training through the use of reflective blogs. Behav Cogn Psychother 2010;38:473-7.
8Murray-García JL, Harrell S, García JA, Gizzi E, Simms-Mackey P. Self-reflection in multicultural training: Be careful what you ask for. Acad Med 2005;80:694-701.
9Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ 2008;337:a1961.
10Delva D, Sargeant J, Miller S, Holland J, Alexiadis Brown P, Leblanc C, et al. Encouraging residents to seek feedback. Med Teach 2013;35:e1625-31.
11Launer J. Giving feedback to medical students and trainees: Rules and realities. Postgrad Med J 2016;92:627-8.
12Baseer N, Mahboob U, Degnan J. Micro-Feedback Training: Learning the art of effective feedback. Pak J Med Sci 2017;33:1525-7.
13Murphy DJ, Bruce DA, Mercer SW, Eva KW. The reliability of workplace-based assessment in postgraduate medical education and training: A national evaluation in general practice in the United Kingdom. Adv Health Sci Educ Theory Pract 2009;14:219-32.
14Teunissen PW, Stapel DA, van der Vleuten C, Scherpbier A, Boor K, Scheele F. Who wants feedback? An investigation of the variables influencing residents' feedback-seeking behavior in relation to night shifts. Acad Med 2009;84:910-7.
15Sargeant J, McNaughton E, Mercer S, Murphy D, Sullivan P, Bruce DA. Providing feedback: Exploring a model (emotion, content, outcomes) for facilitating multisource feedback. Med Teach 2011;33:744-9.
16Clynes MP, Raftery SE. Feedback: An essential element of student learning in clinical practice. Nurse Educ Pract 2008;8:405-11.
17Zehra T, Tariq M, Ali SK, Motiwala A, Boulet J. Challenges of providing timely feedback to residents: Faculty perspectives. J Pak Med Assoc 2015;65:1069-74.
18Schultz KW, Kirby J, Delva D, Godwin M, Verma S, Birtwhistle R, et al. Medical Students' and Residents' preferred site characteristics and preceptor behaviours for learning in the ambulatory setting: A cross-sectional survey. BMC Med Educ 2004;4:12.
19Schartel SA. Giving feedback – An integral part of education. Best Pract Res Clin Anaesthesiol 2012;26:77-87.
20Branch WT Jr., Paranjape A. Feedback and reflection: Teaching methods for clinical settings. Acad Med 2002;77:1185-8.