Among the contemporary recommendations given by the Carnegie Foundation for the advancement of teaching are the need to foster collaborative learning environments and deliberate opportunities for learners to engage in reflective practice. Both of these elements should be embedded in a longitudinal mentoring context, in which feedback is a fundamental element (1).

In the early 80’s, Ende defined feedback as a formative teaching strategy to present information, not judgement, with the purpose of guiding learners’ future performance, thus allowing students to remain on course in reaching their goals (2). Furthermore, he stated that without feedback, “mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved empirically, or not at all” (p. 778) (2). In higher-education institutions, feedback is often conceived as a one-way provision of information from teacher to student, in which no mechanism is deemed necessary to ensure the information received is actually used to improve learning (3). Students’ participation is limited to listening and acting on the information given, without making their own judgments, assuming that they will interpret it the same way the teacher intends (3).

Modern competency-based education programs require students to demonstrate their skills by means of measurable approaches, accomplishing an acceptable degree of consistency as proof of their competence, to practice in their future professional field and to meet the needs of the population and health care systems (4,5). Trainees require access to clinical experiences and deliberate support while receiving training in the workplace, including feedback as a key element, to help them achieve their goals and the learning objectives of the program (6,7,8).

In 2002, Hesketh and Laidlaw presented feedback as a dynamic process serving the purpose of confirming positive behavior by encouraging repetition and correcting negative behavior by encouraging change (9). A decade later, Murdoch-Eaton and Sargeant elaborated more on the concept considering it a formative teaching-learning mechanism to inform and guide development, learning and improvement (10).

The purpose of feedback is to offer not only motivation for the learning process, but equally important, direction for learning in a specific content area or task, whilst serving as a guide to shape the way trainees make sense of the experiences they encounter at the workplace, in order to design a path forward (11,12). It is meant to support the development of the student’s capacity to assess and change the learning behavior, according to personal his/her learning needs (13).

Praising a learner may lead to reinforcement of a set of behaviors, but it does not provide details as to which of the actions should be repeated and which ones could be improved or should be avoided (14). In contrast, feedback provides trainees with relevant information on past performance and reassurance regarding competencies achieved (14). Furthermore, feedback serves to guide learning, reinforce desirable actions, identify areas for improvement and promote reflection, in order to direct future actions and behaviors more effectively (14,15).

When feedback brings to light the gap between current performance and the intended goal and standards towards competency, students can plan for further learning and improve understanding, knowledge and skill acquisition to overcome the discrepancies (8,12,16,17,18). It is important to keep in mind that the strategies applied by teachers and students to reduce the gap may be more or less effective in enhancing learning (17). Among the variables that interact with the feedback process and how effectively it is used, are engagement with the educational process, student achievement level, complexity of the task and prior knowledge (12).

Decades of scholarly literature on this theme have repeatedly evidenced the importance of feedback mechanisms in the development and enhancement of learning (2,19). In Hattie and Timperley’s meta-analysis, feedback is included among the top five factors influencing learners’ achievements (17). In more recent literature, Harden and Laidlaw considered feedback to be one of the four key principles leading to effective learning (20). Holmboe et al. claim that lack of feedback provision is one of the most serious deficiencies in medical education, and Weinstein advocates that the more pervasive problem of insufficient feedback is that it impedes efforts to support learners in reaching their maximum potential (21,22).

When students do not receive effective feedback, they need to rely solely on self-assessment to evaluate the adequacy and quality of their performance and of the clinical skills they are learning (11). This poses a serious problem, since the literature has repeatedly demonstrated the natural human tendency toward inaccuracy in self-assessment. High performers tend to underestimate themselves, while more inexperienced or overconfident learners overestimate their performance (23,24,25). Furthermore, studies have demonstrated inexperienced learners as being inconsistent in identifying their own strengths and weaknesses (14). Therefore, self-assessment as judgement of performance effectiveness and maintenance of professional competence cannot be the only or even the main means to define learning needs (11,24,26,27).

Providing trainees with feedback lends them the opportunity to benchmark their own assessment against external appraisal, and cultivates a reflective practice on behavior, attitude and performance (28). It is important for learners to recognize the importance of external input on their learning process, in order to be able to apply the feedback received to the development of self-assessment skills through reflective practice. The skills of reflective practice and self-assessment are essential characteristics of professional competence and require practice and persistence through deliberate opportunities (24,29,30). Learning to judge themselves and the work of others and determine how their self-analysis on their performance compares to external appraisal, raises an awareness that drives the planning of further learning towards quality performance (3).

Failure to provide feedback may bring upon an additional unwanted outcome. It can be misinterpreted as an implicit approval of the learner’s performance and/or knowledge (8,14). Medical education characterizes itself by a system of gradual decrease in supervision. Therefore, leaving mistakes uncorrected may lead to the trainee perpetuating these errors and even teaching them to less experienced students or future learners (14).

It is for these reasons that since 2006, the body responsible for accrediting US medical schools highlights the importance of incorporating formal feedback in courses and clerkships, in order for students to acknowledge and understand their deficiencies and work towards overcoming them, with the aim of improving performance and attain competence (31).

Feedback to be provided to a trainee must be focused on directly observed behavior or performance of a task, that is amenable to change and that can be constructively corrected by offering strategies for behavior modification (8,18). In other words, insight provided by educators should be focused on learner’s decisions and actions, not on intentions and/or interpretations (24). Being the direct observer of the student, the preceptor can provide real and specific examples of the actual performance and compare it to the desirable behavior according to standards, demonstrating the gap mentioned previously (24). This renders specificity to the information provided, and teachers can thus ensure honesty and accuracy of the feedback process (35,36).

For greater effectiveness, the comments must be clear, descriptive rather than evaluative, meaningful, purposeful, compatible with the student’s prior knowledge, provide logical connections when required and linked to clear and specific learning needs and goals (8,17,36). Tutors require a clear understanding of the learning goals for each stage of the curriculum, in order to link performance to competency-based learning objectives, hereby increasing feedback specificity (18). Explicit suggestions must be included to either further build on strengths or overcome weaknesses (24,37).

Recommendations are in place indicating that direct observation of a trainee by the same preceptor, in a number of different settings, over a reasonable time span, is desirable for the feedback process to be accurate as well as constructive (25,38). In the event of serious time constrains due to, for example, short rotations, that do not allow for repeated observations, constructive input can still be provided. When multiple data of this sort are gathered from several tutors, across different rotations over time, the information obtained can create a comprehensive picture of the educational development of the learner (33).

Another important aspect to bear in mind refers to the amount of information conveyed during the encounter. When confronted with a long list of issues, students may feel overwhelmed and become disengaged from the feedback process. Therefore, it is best to prioritize the most important aspects to be covered during each session (24,33,39).

Studies exploring the perceptions and expectations of feedback receivers have evidenced that the most effective feedback for sustained improvement is the one offered by content experts (39,40,41). Some authors recommend that as the trainee progresses in the educational process, more experienced physicians should observe the performance and provide the corresponding input (15).

Every feedback session to be held requires a previous and careful planning before the actual delivery of the information.

Engaging students in dialogue with the aim of raising awareness of what is considered quality performance and aligning learning objectives, tasks and strategies for behavior modification and enhancement constitute the substrate for a collaborative learning effort (3,18). Effective feedback improves learners’ capacity in regard to lifelong learning, by developing skills for setting goals, monitoring own learning processes and assimilating the input towards enhancement of performance, both in the educational and future professional scenarios (13).

Veloski et al. state that feedback can change clinical performance when systematically delivered from credible sources, and practiced within a robust framework embedded in literature (48). Trainees in the medical field have characterized their learning experience as effective when a clear link exists to the provision of feedback from the teaching staff (49). Nonetheless, the application and good use of the information received through feedback demonstrates a considerable variance among students. This is possibly due to differences in the degree of acceptance and engagement with the strategy and personal outcomes of previous feedback experiences (49). Another factor that could contribute to this variability is the impact feedback has on the learner, since it is dependent on the individual desire to improve and the self-confidence in the ability to do so (50).

Evidence has shown feedback to be a strong motivational driving force and hence, an influential factor on learning approach (51). Academic achievement and performance are directly influenced by the student’s adopted learning approach. In turn, a positive relationship has been demonstrated between deep learning approach and high academic achievement (51,52). Engaging effectively with feedback allows learners to incorporate longer-term changes in learning approach, to transfer knowledge to other tasks and/or performance, to apply higher-order learning skills to build on pass experiences in order to improve and to generate their own internal feedback (6,53).

With an effective feedback culture in place, students learn to accept the reality that mistakes are inherent to any learning process and should be considered learning opportunities rather than failures. The role of supervisors is to support trainees in understanding these mistakes, work to improve and avoid repeating them in the future (54).

Several studies have explored the perception of trainees and students as to characteristics, behaviors and actions that serve as positive influential factors for feedback processes. For the purpose of this paper, they will be classified in three groups as pertaining to the teacher, the program or the learner.

More recent literature in this field has emphasized the need to explore the issues that might present as barriers for effective feedback encounters, since one of the major shortcomings in medical education has been to provide high quality feedback, conductive to improvement in learners’ performance (56). These factors will also be classified in three groups, as pertaining the teaching staff, the curriculum or the trainees.

Lefroy et al. (37) offered a new, more comprehensive definition of feedback that should be embraced in all institutions with modern medical education curricula. This definition states: “Helpful feedback is a supportive conversation that clarifies the trainees’ awareness of their developing competencies, enhances their self-efficacy for making progress, challenges them to set objectives for improvement and facilitates their development of strategies to enable that improvement to occur” (p. 297).

Feedback, within these more novel approaches, should be considered as a method of formative assessment for learning, instead of assessment of learning. It should be established in all medical education curricula as an indispensable strategy, based on the best available evidence and within a setting of mutual respect and trust, providing assurance that preceptors and learners are working as a team towards common goals. Implementing this valuable educational mechanism with consistency, promotes a culture of continuous life-long learning, improvement and growth in achieving curricular milestones, high-quality standards for medical care, patient safety and professional satisfaction.

Adopting feedback properly enables medical educators and learners to utilize assessment experiences beyond their inherent judgmental purpose and rather, turn them into opportunities to foster learner development. Placing greater value on formative assessment and feedback is mandatory in modern medical education, in order to provide graduates with the required competencies that were not emphasized enough in traditional curricula.

Conflict of interest: none