Lauren Peccoralo, MD

Feedback has long been recognized as pivotal to the attainment of clinical acumen and skills in medical training.1 Formative feedback can give trainees insight into their strengths and weaknesses, and provide them with clear goals and methods to attain those goals.1, 2 In fact, feedback given regularly over time by a respected figure has shown to improve physician performance.3 However, most faculty are not trained to provide effective feedback. As a result, supervisors often believe they are giving more feedback than trainees believe they are receiving, and residents receive little feedback that they perceive as useful.4 Most residents receive little to no feedback on their communications skills4 or professionalism,5 and rarely receive corrective feedback.6, 7

Faculty may fail to give feedback to residents for a number of reasons. Those barriers most commonly cited in the literature are discomfort with criticizing residents,6, 7 lack of time,4 and lack of direct observation of residents in clinical settings.810 Several studies have looked at tools to guide feedback and address the barrier of discomfort with criticism.6, 7, 11 Some showed improvements in overall feedback, though often supervisors gave only positive feedback and avoided giving feedback about weaknesses.6, 7, 11 Despite the recognition of lack of time as a barrier to feedback,4 most studies on feedback interventions thus far have not included setting aside time for the feedback to occur.6, 7, 11, 12 Finally, a number of studies utilized objective structured clinical examinations (OSCEs) coupled with immediate feedback to improve direct observation of residents, with success in improving feedback related to the encounter.9, 10, 13 To address the gaps in the current literature, the goals of our study were to address 2 specific barriers to feedback for residents: lack of time and discomfort with giving feedback.

The aim of this study was to improve Internal Medicine (IM) residents' and attendings' experiences with feedback on the wards using a pocket card and a dedicated feedback session. We developed and evaluated the pocket feedback card and session for faculty to improve the quality and frequency of their feedback to residents in the inpatient setting. We performed a randomized trial to evaluate our intervention. We hypothesized that the intervention would: 1) improve the quality and quantity of attendings' feedback given to IM ward residents; and 2) improve attendings' comfort with feedback delivery on the wards.

PARTICIPANTS AND METHODS

Intervention Design

We designed a pocket feedback card to guide a feedback session and assist attendings in giving useful feedback to IM residents on the wards (Figure 1).14 The individual items and categories were adapted from the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements Core Competencies section and were revised via the expert consensus of the authors.14 We included 20 items related to resident skills, knowledge, attitudes, and behaviors important to the care of hospitalized patients, grouped under the 6 ACGME core competency domains.14 Many of these items correspond to competencies in the Society of Hospital Medicine (SHM) Core Competencies; in particular, the categories of Systems‐Based Practice and Practice‐Based Learning mirror competencies in the SHM Core Competencies Healthcare Systems chapter.15 Each item utilized a 5‐point Likert scale (1 = very poor, 3 = at expected level, 5 = superior) to evaluate resident performance (Figure 1). We created this card to serve as a directive and specific guide for attendings to provide feedback about specific domains and to give more constructive feedback. The card was to be used during a specific dedicated feedback session in order to overcome the commonly cited barrier of lack of time.

Figure 1

RESULTS

During the 6‐month study period, 34 teaching attendings (over 36 attending inpatient blocks) and 93 IM residents (over 111 resident inpatient blocks) participated in the study. Thirty‐four of 36 attending surveys and 96 of 111 resident surveys were completed. The overall survey response rates for residents and attendings were 85% and 94%, respectively. Two attendings participated during 2 separate blocks, first in the control group and then in the intervention group, and 18 residents participated during 2 separate blocks. No attendings or residents participated more than twice.

Resident survey response rate was 81.2% in the intervention group and 87.3% in the control group (Table 1). Residents in the intervention group reported receiving more feedback regarding skills they did well (89.7% vs 63.6%, P = 0.004) and skills needing improvement (51.3% vs 25.5%, P = 0.02) than those in the control group. In addition, more intervention residents reported receiving useful information regarding how to improve their skills (53.8% vs 27.3%, P = 0.01), and reported actually improving both their clinical skills (61.5% vs 27.8%, P = 0.001) and their professionalism/communication skills (51.3% vs 29.1%, P = 0.03) based on feedback received from attendings.

The attending survey response rates for the intervention and control groups were 100% and 90%, respectively. In general, both groups of attendings reported that they were comfortable giving feedback and that they did, in fact, give feedback in each area during their ward block (Table 2). More intervention attendings felt that at least 1 of their residents improved their professionalism/communication skills based on the feedback given (76.9% vs 31.1%, P = 0.02). There were no other significant differences between the groups of attendings.

Intervention attendings also shared their attitudes toward the feedback card and session. A majority felt that using 1 attending rounds as a feedback session helped create a dedicated time for giving feedback (68.8%), and that the feedback card helped them to give specific, constructive feedback (62.5%). Most attendings reported they would use the feedback card and session again during future inpatient blocks (81%), and would recommend them to other attendings (75%).

Qualitative data from intervention attending interviews revealed further thoughts about the feedback card and feedback session. Most attendings interviewed (7/8) felt that the card was useful for the structure and topic guidance it provided. Half felt that setting aside time for feedback was the more useful component. The other half reported that, because they usually set aside time for feedback regardless, the card was more useful. None of the attendings felt that the feedback card or session was detrimental for patient care or education, and many said that the intervention had positive effects on these areas. For example, 1 attending said that the session added to patient care because I used particular [patient] cases as examples for giving feedback.

DISCUSSION

In this randomized study, we found that a simple pocket feedback card and dedicated feedback session was acceptable to ward attendings and improved resident satisfaction with feedback. Unlike most prior studies of feedback, we demonstrated more feedback around skills needing improvement, and intervention residents felt the feedback they received helped them improve their skills. Our educational intervention was unique in that it combined a pocket card to structure feedback content and dedicated time to structure the feedback process, to address 2 of the major barriers to giving feedback: lack of time and lack of comfort.

The pocket card itself as a tool for improving feedback is innovative and valuable. As a short but directive guide, the card supports attendings' delivery of relevant and specific feedback about residents' performance, and because it is based on the ACGME competencies, it may help attendings focus feedback on areas in which they will later evaluate residents. The inclusion of a prespecified time for giving feedback was important as well, in that it allowed for face‐to‐face feedback to occur, as opposed to a passing comment after a presentation or brief notes in a written final evaluation. Both the card and the feedback session seemed equally important for the success of this intervention, with attitudes varying based on individual attending preferences. Those who usually set aside time for feedback on their own found the card more useful, whereas those who had more trouble finding time for feedback found the specific session more useful. Most attendings found the intervention as a whole helpful, and without any detrimental effects on patient care or education. The card and session may be particularly valuable for hospital attendings, given their growing presence as teachers and supervisors for residents, and their busy days on the wards.

Our study results have important implications for resident training in the hospital. Improving resident receipt of feedback about strengths and weaknesses is an ACGME training requirement, and specific guidance about how to improve skills is critical for focusing improvement efforts. Previous studies have demonstrated that directive feedback in medical training can lead to a variety of performance improvements, including better evaluations by other professionals,9, 16 and objective improvements in resident communication skills,17 chart documentation,18 and clinical management of patients.11, 15, 19 By improving the quality of feedback across several domains and facilitating the feedback process, our intervention may lead to similar improvements. Future studies should examine the global impact of guided feedback as in our study. Perhaps most importantly, attendings found the intervention acceptable and would recommend its use, implying longer term sustainability of its integration into the hospital routine.

One strength of our study was its prospective randomized design. Despite the importance of rigor in medical education research, there remains a paucity of randomized studies to evaluate educational interventions for residents in inpatient settings. Few studies of feedback interventions in particular have performed randomized trials,5, 6, 11 and only one has examined a feedback intervention in a randomized fashion in the inpatient setting.12 This evaluation of a 20‐minute intervention, and a reminder card for supervising attendings to improve written and verbal feedback to residents, modestly improved the amount of verbal feedback given to residents, but did not impact the number of residents receiving mid‐rotation feedback or feedback overall as our study did by report.12

There were several important limitations to our study. First, because this was a single institution study, we only achieved modest sample sizes, particularly in the attending groups, and were unable to assess all of the differences in attending attitudes related to feedback. Second, control and intervention participants were on service simultaneously, which may have led to contamination of the control group and an underestimation of the true impact of our intervention. Since residents were not exclusive to 1 study group on 1 occasion (18 of the 93 residents participated during 2 separate blocks), our results may be biased. In particular, those residents who had the intervention first, and were subsequently in the control group, may have rated the control experience worse than they would have otherwise, creating a bias in favor of a positive result for our intervention. Nonetheless, we believe this situation was uncommon and the potential associated bias minimal. Further, this study assessed attitudes related to feedback and self‐reported knowledge and skills, but did not directly assess resident knowledge, skills, or patient outcomes. We recognize the importance of these outcomes and hope that future interventions can determine these important downstream effects of feedback. We were also unable to assess the card and session's impact on attendings' comfort with feedback, because most attendings in both groups reported feeling comfortable giving feedback. This result may indicate that attendings actually are comfortable giving feedback, or may suggest some element of social desirability bias. Finally, in this study, we designed an intervention which combined the pocket card and dedicated feedback time. We did not quantitatively examine the effect of either component alone, and it is unclear if offering the feedback card without protected time or offering protected time without a guide would have impacted feedback on the wards. However, qualitative data from our study support the use of both components, and implementing the 2 components together is feasible in any inpatient teaching setting.

Despite these limitations, protected time for feedback guided by a pocket feedback card is a simple intervention that appears to improve feedback quantity and quality for ward residents, and guides them to improve their performance. Our low‐intensity intervention helped attendings give residents the tools to improve their clinical and communication skills. An opportunity to make a positive impact on resident education with such a small intervention is rare. The use of a feedback card with protected feedback time could be easily implemented in any training program, and is a valuable tool for busy hospitalists who are more commonly supervising residents on their inpatient rotations.

Feedback has long been recognized as pivotal to the attainment of clinical acumen and skills in medical training.1 Formative feedback can give trainees insight into their strengths and weaknesses, and provide them with clear goals and methods to attain those goals.1, 2 In fact, feedback given regularly over time by a respected figure has shown to improve physician performance.3 However, most faculty are not trained to provide effective feedback. As a result, supervisors often believe they are giving more feedback than trainees believe they are receiving, and residents receive little feedback that they perceive as useful.4 Most residents receive little to no feedback on their communications skills4 or professionalism,5 and rarely receive corrective feedback.6, 7

Faculty may fail to give feedback to residents for a number of reasons. Those barriers most commonly cited in the literature are discomfort with criticizing residents,6, 7 lack of time,4 and lack of direct observation of residents in clinical settings.810 Several studies have looked at tools to guide feedback and address the barrier of discomfort with criticism.6, 7, 11 Some showed improvements in overall feedback, though often supervisors gave only positive feedback and avoided giving feedback about weaknesses.6, 7, 11 Despite the recognition of lack of time as a barrier to feedback,4 most studies on feedback interventions thus far have not included setting aside time for the feedback to occur.6, 7, 11, 12 Finally, a number of studies utilized objective structured clinical examinations (OSCEs) coupled with immediate feedback to improve direct observation of residents, with success in improving feedback related to the encounter.9, 10, 13 To address the gaps in the current literature, the goals of our study were to address 2 specific barriers to feedback for residents: lack of time and discomfort with giving feedback.

The aim of this study was to improve Internal Medicine (IM) residents' and attendings' experiences with feedback on the wards using a pocket card and a dedicated feedback session. We developed and evaluated the pocket feedback card and session for faculty to improve the quality and frequency of their feedback to residents in the inpatient setting. We performed a randomized trial to evaluate our intervention. We hypothesized that the intervention would: 1) improve the quality and quantity of attendings' feedback given to IM ward residents; and 2) improve attendings' comfort with feedback delivery on the wards.

PARTICIPANTS AND METHODS

Intervention Design

We designed a pocket feedback card to guide a feedback session and assist attendings in giving useful feedback to IM residents on the wards (Figure 1).14 The individual items and categories were adapted from the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements Core Competencies section and were revised via the expert consensus of the authors.14 We included 20 items related to resident skills, knowledge, attitudes, and behaviors important to the care of hospitalized patients, grouped under the 6 ACGME core competency domains.14 Many of these items correspond to competencies in the Society of Hospital Medicine (SHM) Core Competencies; in particular, the categories of Systems‐Based Practice and Practice‐Based Learning mirror competencies in the SHM Core Competencies Healthcare Systems chapter.15 Each item utilized a 5‐point Likert scale (1 = very poor, 3 = at expected level, 5 = superior) to evaluate resident performance (Figure 1). We created this card to serve as a directive and specific guide for attendings to provide feedback about specific domains and to give more constructive feedback. The card was to be used during a specific dedicated feedback session in order to overcome the commonly cited barrier of lack of time.

Figure 1

RESULTS

During the 6‐month study period, 34 teaching attendings (over 36 attending inpatient blocks) and 93 IM residents (over 111 resident inpatient blocks) participated in the study. Thirty‐four of 36 attending surveys and 96 of 111 resident surveys were completed. The overall survey response rates for residents and attendings were 85% and 94%, respectively. Two attendings participated during 2 separate blocks, first in the control group and then in the intervention group, and 18 residents participated during 2 separate blocks. No attendings or residents participated more than twice.

Resident survey response rate was 81.2% in the intervention group and 87.3% in the control group (Table 1). Residents in the intervention group reported receiving more feedback regarding skills they did well (89.7% vs 63.6%, P = 0.004) and skills needing improvement (51.3% vs 25.5%, P = 0.02) than those in the control group. In addition, more intervention residents reported receiving useful information regarding how to improve their skills (53.8% vs 27.3%, P = 0.01), and reported actually improving both their clinical skills (61.5% vs 27.8%, P = 0.001) and their professionalism/communication skills (51.3% vs 29.1%, P = 0.03) based on feedback received from attendings.

The attending survey response rates for the intervention and control groups were 100% and 90%, respectively. In general, both groups of attendings reported that they were comfortable giving feedback and that they did, in fact, give feedback in each area during their ward block (Table 2). More intervention attendings felt that at least 1 of their residents improved their professionalism/communication skills based on the feedback given (76.9% vs 31.1%, P = 0.02). There were no other significant differences between the groups of attendings.

Intervention attendings also shared their attitudes toward the feedback card and session. A majority felt that using 1 attending rounds as a feedback session helped create a dedicated time for giving feedback (68.8%), and that the feedback card helped them to give specific, constructive feedback (62.5%). Most attendings reported they would use the feedback card and session again during future inpatient blocks (81%), and would recommend them to other attendings (75%).

Qualitative data from intervention attending interviews revealed further thoughts about the feedback card and feedback session. Most attendings interviewed (7/8) felt that the card was useful for the structure and topic guidance it provided. Half felt that setting aside time for feedback was the more useful component. The other half reported that, because they usually set aside time for feedback regardless, the card was more useful. None of the attendings felt that the feedback card or session was detrimental for patient care or education, and many said that the intervention had positive effects on these areas. For example, 1 attending said that the session added to patient care because I used particular [patient] cases as examples for giving feedback.

DISCUSSION

In this randomized study, we found that a simple pocket feedback card and dedicated feedback session was acceptable to ward attendings and improved resident satisfaction with feedback. Unlike most prior studies of feedback, we demonstrated more feedback around skills needing improvement, and intervention residents felt the feedback they received helped them improve their skills. Our educational intervention was unique in that it combined a pocket card to structure feedback content and dedicated time to structure the feedback process, to address 2 of the major barriers to giving feedback: lack of time and lack of comfort.

The pocket card itself as a tool for improving feedback is innovative and valuable. As a short but directive guide, the card supports attendings' delivery of relevant and specific feedback about residents' performance, and because it is based on the ACGME competencies, it may help attendings focus feedback on areas in which they will later evaluate residents. The inclusion of a prespecified time for giving feedback was important as well, in that it allowed for face‐to‐face feedback to occur, as opposed to a passing comment after a presentation or brief notes in a written final evaluation. Both the card and the feedback session seemed equally important for the success of this intervention, with attitudes varying based on individual attending preferences. Those who usually set aside time for feedback on their own found the card more useful, whereas those who had more trouble finding time for feedback found the specific session more useful. Most attendings found the intervention as a whole helpful, and without any detrimental effects on patient care or education. The card and session may be particularly valuable for hospital attendings, given their growing presence as teachers and supervisors for residents, and their busy days on the wards.

Our study results have important implications for resident training in the hospital. Improving resident receipt of feedback about strengths and weaknesses is an ACGME training requirement, and specific guidance about how to improve skills is critical for focusing improvement efforts. Previous studies have demonstrated that directive feedback in medical training can lead to a variety of performance improvements, including better evaluations by other professionals,9, 16 and objective improvements in resident communication skills,17 chart documentation,18 and clinical management of patients.11, 15, 19 By improving the quality of feedback across several domains and facilitating the feedback process, our intervention may lead to similar improvements. Future studies should examine the global impact of guided feedback as in our study. Perhaps most importantly, attendings found the intervention acceptable and would recommend its use, implying longer term sustainability of its integration into the hospital routine.

One strength of our study was its prospective randomized design. Despite the importance of rigor in medical education research, there remains a paucity of randomized studies to evaluate educational interventions for residents in inpatient settings. Few studies of feedback interventions in particular have performed randomized trials,5, 6, 11 and only one has examined a feedback intervention in a randomized fashion in the inpatient setting.12 This evaluation of a 20‐minute intervention, and a reminder card for supervising attendings to improve written and verbal feedback to residents, modestly improved the amount of verbal feedback given to residents, but did not impact the number of residents receiving mid‐rotation feedback or feedback overall as our study did by report.12

There were several important limitations to our study. First, because this was a single institution study, we only achieved modest sample sizes, particularly in the attending groups, and were unable to assess all of the differences in attending attitudes related to feedback. Second, control and intervention participants were on service simultaneously, which may have led to contamination of the control group and an underestimation of the true impact of our intervention. Since residents were not exclusive to 1 study group on 1 occasion (18 of the 93 residents participated during 2 separate blocks), our results may be biased. In particular, those residents who had the intervention first, and were subsequently in the control group, may have rated the control experience worse than they would have otherwise, creating a bias in favor of a positive result for our intervention. Nonetheless, we believe this situation was uncommon and the potential associated bias minimal. Further, this study assessed attitudes related to feedback and self‐reported knowledge and skills, but did not directly assess resident knowledge, skills, or patient outcomes. We recognize the importance of these outcomes and hope that future interventions can determine these important downstream effects of feedback. We were also unable to assess the card and session's impact on attendings' comfort with feedback, because most attendings in both groups reported feeling comfortable giving feedback. This result may indicate that attendings actually are comfortable giving feedback, or may suggest some element of social desirability bias. Finally, in this study, we designed an intervention which combined the pocket card and dedicated feedback time. We did not quantitatively examine the effect of either component alone, and it is unclear if offering the feedback card without protected time or offering protected time without a guide would have impacted feedback on the wards. However, qualitative data from our study support the use of both components, and implementing the 2 components together is feasible in any inpatient teaching setting.

Despite these limitations, protected time for feedback guided by a pocket feedback card is a simple intervention that appears to improve feedback quantity and quality for ward residents, and guides them to improve their performance. Our low‐intensity intervention helped attendings give residents the tools to improve their clinical and communication skills. An opportunity to make a positive impact on resident education with such a small intervention is rare. The use of a feedback card with protected feedback time could be easily implemented in any training program, and is a valuable tool for busy hospitalists who are more commonly supervising residents on their inpatient rotations.

Feedback has long been recognized as pivotal to the attainment of clinical acumen and skills in medical training.1 Formative feedback can give trainees insight into their strengths and weaknesses, and provide them with clear goals and methods to attain those goals.1, 2 In fact, feedback given regularly over time by a respected figure has shown to improve physician performance.3 However, most faculty are not trained to provide effective feedback. As a result, supervisors often believe they are giving more feedback than trainees believe they are receiving, and residents receive little feedback that they perceive as useful.4 Most residents receive little to no feedback on their communications skills4 or professionalism,5 and rarely receive corrective feedback.6, 7

Faculty may fail to give feedback to residents for a number of reasons. Those barriers most commonly cited in the literature are discomfort with criticizing residents,6, 7 lack of time,4 and lack of direct observation of residents in clinical settings.810 Several studies have looked at tools to guide feedback and address the barrier of discomfort with criticism.6, 7, 11 Some showed improvements in overall feedback, though often supervisors gave only positive feedback and avoided giving feedback about weaknesses.6, 7, 11 Despite the recognition of lack of time as a barrier to feedback,4 most studies on feedback interventions thus far have not included setting aside time for the feedback to occur.6, 7, 11, 12 Finally, a number of studies utilized objective structured clinical examinations (OSCEs) coupled with immediate feedback to improve direct observation of residents, with success in improving feedback related to the encounter.9, 10, 13 To address the gaps in the current literature, the goals of our study were to address 2 specific barriers to feedback for residents: lack of time and discomfort with giving feedback.

The aim of this study was to improve Internal Medicine (IM) residents' and attendings' experiences with feedback on the wards using a pocket card and a dedicated feedback session. We developed and evaluated the pocket feedback card and session for faculty to improve the quality and frequency of their feedback to residents in the inpatient setting. We performed a randomized trial to evaluate our intervention. We hypothesized that the intervention would: 1) improve the quality and quantity of attendings' feedback given to IM ward residents; and 2) improve attendings' comfort with feedback delivery on the wards.

PARTICIPANTS AND METHODS

Intervention Design

We designed a pocket feedback card to guide a feedback session and assist attendings in giving useful feedback to IM residents on the wards (Figure 1).14 The individual items and categories were adapted from the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements Core Competencies section and were revised via the expert consensus of the authors.14 We included 20 items related to resident skills, knowledge, attitudes, and behaviors important to the care of hospitalized patients, grouped under the 6 ACGME core competency domains.14 Many of these items correspond to competencies in the Society of Hospital Medicine (SHM) Core Competencies; in particular, the categories of Systems‐Based Practice and Practice‐Based Learning mirror competencies in the SHM Core Competencies Healthcare Systems chapter.15 Each item utilized a 5‐point Likert scale (1 = very poor, 3 = at expected level, 5 = superior) to evaluate resident performance (Figure 1). We created this card to serve as a directive and specific guide for attendings to provide feedback about specific domains and to give more constructive feedback. The card was to be used during a specific dedicated feedback session in order to overcome the commonly cited barrier of lack of time.

Figure 1

RESULTS

During the 6‐month study period, 34 teaching attendings (over 36 attending inpatient blocks) and 93 IM residents (over 111 resident inpatient blocks) participated in the study. Thirty‐four of 36 attending surveys and 96 of 111 resident surveys were completed. The overall survey response rates for residents and attendings were 85% and 94%, respectively. Two attendings participated during 2 separate blocks, first in the control group and then in the intervention group, and 18 residents participated during 2 separate blocks. No attendings or residents participated more than twice.

Resident survey response rate was 81.2% in the intervention group and 87.3% in the control group (Table 1). Residents in the intervention group reported receiving more feedback regarding skills they did well (89.7% vs 63.6%, P = 0.004) and skills needing improvement (51.3% vs 25.5%, P = 0.02) than those in the control group. In addition, more intervention residents reported receiving useful information regarding how to improve their skills (53.8% vs 27.3%, P = 0.01), and reported actually improving both their clinical skills (61.5% vs 27.8%, P = 0.001) and their professionalism/communication skills (51.3% vs 29.1%, P = 0.03) based on feedback received from attendings.

The attending survey response rates for the intervention and control groups were 100% and 90%, respectively. In general, both groups of attendings reported that they were comfortable giving feedback and that they did, in fact, give feedback in each area during their ward block (Table 2). More intervention attendings felt that at least 1 of their residents improved their professionalism/communication skills based on the feedback given (76.9% vs 31.1%, P = 0.02). There were no other significant differences between the groups of attendings.

Intervention attendings also shared their attitudes toward the feedback card and session. A majority felt that using 1 attending rounds as a feedback session helped create a dedicated time for giving feedback (68.8%), and that the feedback card helped them to give specific, constructive feedback (62.5%). Most attendings reported they would use the feedback card and session again during future inpatient blocks (81%), and would recommend them to other attendings (75%).

Qualitative data from intervention attending interviews revealed further thoughts about the feedback card and feedback session. Most attendings interviewed (7/8) felt that the card was useful for the structure and topic guidance it provided. Half felt that setting aside time for feedback was the more useful component. The other half reported that, because they usually set aside time for feedback regardless, the card was more useful. None of the attendings felt that the feedback card or session was detrimental for patient care or education, and many said that the intervention had positive effects on these areas. For example, 1 attending said that the session added to patient care because I used particular [patient] cases as examples for giving feedback.

DISCUSSION

In this randomized study, we found that a simple pocket feedback card and dedicated feedback session was acceptable to ward attendings and improved resident satisfaction with feedback. Unlike most prior studies of feedback, we demonstrated more feedback around skills needing improvement, and intervention residents felt the feedback they received helped them improve their skills. Our educational intervention was unique in that it combined a pocket card to structure feedback content and dedicated time to structure the feedback process, to address 2 of the major barriers to giving feedback: lack of time and lack of comfort.

The pocket card itself as a tool for improving feedback is innovative and valuable. As a short but directive guide, the card supports attendings' delivery of relevant and specific feedback about residents' performance, and because it is based on the ACGME competencies, it may help attendings focus feedback on areas in which they will later evaluate residents. The inclusion of a prespecified time for giving feedback was important as well, in that it allowed for face‐to‐face feedback to occur, as opposed to a passing comment after a presentation or brief notes in a written final evaluation. Both the card and the feedback session seemed equally important for the success of this intervention, with attitudes varying based on individual attending preferences. Those who usually set aside time for feedback on their own found the card more useful, whereas those who had more trouble finding time for feedback found the specific session more useful. Most attendings found the intervention as a whole helpful, and without any detrimental effects on patient care or education. The card and session may be particularly valuable for hospital attendings, given their growing presence as teachers and supervisors for residents, and their busy days on the wards.

Our study results have important implications for resident training in the hospital. Improving resident receipt of feedback about strengths and weaknesses is an ACGME training requirement, and specific guidance about how to improve skills is critical for focusing improvement efforts. Previous studies have demonstrated that directive feedback in medical training can lead to a variety of performance improvements, including better evaluations by other professionals,9, 16 and objective improvements in resident communication skills,17 chart documentation,18 and clinical management of patients.11, 15, 19 By improving the quality of feedback across several domains and facilitating the feedback process, our intervention may lead to similar improvements. Future studies should examine the global impact of guided feedback as in our study. Perhaps most importantly, attendings found the intervention acceptable and would recommend its use, implying longer term sustainability of its integration into the hospital routine.

One strength of our study was its prospective randomized design. Despite the importance of rigor in medical education research, there remains a paucity of randomized studies to evaluate educational interventions for residents in inpatient settings. Few studies of feedback interventions in particular have performed randomized trials,5, 6, 11 and only one has examined a feedback intervention in a randomized fashion in the inpatient setting.12 This evaluation of a 20‐minute intervention, and a reminder card for supervising attendings to improve written and verbal feedback to residents, modestly improved the amount of verbal feedback given to residents, but did not impact the number of residents receiving mid‐rotation feedback or feedback overall as our study did by report.12

There were several important limitations to our study. First, because this was a single institution study, we only achieved modest sample sizes, particularly in the attending groups, and were unable to assess all of the differences in attending attitudes related to feedback. Second, control and intervention participants were on service simultaneously, which may have led to contamination of the control group and an underestimation of the true impact of our intervention. Since residents were not exclusive to 1 study group on 1 occasion (18 of the 93 residents participated during 2 separate blocks), our results may be biased. In particular, those residents who had the intervention first, and were subsequently in the control group, may have rated the control experience worse than they would have otherwise, creating a bias in favor of a positive result for our intervention. Nonetheless, we believe this situation was uncommon and the potential associated bias minimal. Further, this study assessed attitudes related to feedback and self‐reported knowledge and skills, but did not directly assess resident knowledge, skills, or patient outcomes. We recognize the importance of these outcomes and hope that future interventions can determine these important downstream effects of feedback. We were also unable to assess the card and session's impact on attendings' comfort with feedback, because most attendings in both groups reported feeling comfortable giving feedback. This result may indicate that attendings actually are comfortable giving feedback, or may suggest some element of social desirability bias. Finally, in this study, we designed an intervention which combined the pocket card and dedicated feedback time. We did not quantitatively examine the effect of either component alone, and it is unclear if offering the feedback card without protected time or offering protected time without a guide would have impacted feedback on the wards. However, qualitative data from our study support the use of both components, and implementing the 2 components together is feasible in any inpatient teaching setting.

Despite these limitations, protected time for feedback guided by a pocket feedback card is a simple intervention that appears to improve feedback quantity and quality for ward residents, and guides them to improve their performance. Our low‐intensity intervention helped attendings give residents the tools to improve their clinical and communication skills. An opportunity to make a positive impact on resident education with such a small intervention is rare. The use of a feedback card with protected feedback time could be easily implemented in any training program, and is a valuable tool for busy hospitalists who are more commonly supervising residents on their inpatient rotations.