This document provides guidance on giving effective constructive feedback to trainees. It emphasizes the importance of feedback for learning and outlines the three levels of feedback: Level 1 involves objectively describing the observed behavior, Level 2 involves sharing one's personal reaction, and Level 3 involves predicting outcomes. The "Ask-Tell-Ask" approach is recommended, which involves asking the trainee for a self-assessment, telling them the observed feedback including positives and areas for improvement, and asking for their understanding and future plans. Video vignettes demonstrate examples of using this approach. The document stresses the value of feedback for learning and reinforcing good performance.

2. Feel
Learning Objectives
• The benefit and application of providing
constructive feedback to trainees.
• The basic characteristics and the three levels
of constructive feedback.
• Eager to further develop your ability to provide
constructive feedback to trainees.
• More comfortable in giving and receiving feedback.
• Use all three levels of constructive feedback.
• Use the “Ask – Tell – Ask” approach in giving
and receiving feedback.
Know
Do

3. Importance of Feedback
Without feedback,
mistakes go uncorrected,
good performance is not
reinforced, and clinical
competence is achieved
empirically or, not at all.
Ende, J. (1983). Feedback in clinical medical education. JAMA 250:777-781.

4. Ende, J. (1983). Feedback in clinical medical education. JAMA 250:777-781.
Three Critical Questions

5. Level 1 Level 2 Level 3
What you saw
the trainee do
Your personal
reaction
(not judgment)
Your prediction
of the likely
outcome
of this behavior
Three Levels of Feedback
PEP2 Facilitator’s Module 6 (Feedback), p. 6.4.

6. Characteristics of Effective
Feedback
 Well timed and expected
 Based on first-hand data
 Regulated in quantity
 Phrased in descriptive language, based
on specific remedial behaviors
 Should be undertaken with teacher and
learner working as allies with common goals
Ende, J. (1983). Feedback in clinical medical education. JAMA 250:777-781.

7. OLD
Praise
Criticism
Praise
NEW
Ask
Tell
Ask
The Feedback Sandwich
French, J.C., et al, (2015). Targeted Feedback in the Milestones Era: Utilization
of the Ask-Tell-Ask Feedback Model to Promote Reflection and Self-Assessment.
Journal of Surgical Education 72(6), e274-e279.

8.  Ask learner to self-assess
 Begin a conversation
 Assess learner’s insight and stage of
learning
ASK

9.  What you observed: diagnosis and explanation
 React to the learner’s observation
 Provide feedback on self-assessment
(include both positive and corrective elements)
TELL

10.  Check recipient’s understanding
 Discuss strategies for improvement
 Ask “What could you do differently?”
 Offer suggestions
 Commit to monitoring improvement together
ASK again!

11. Limit the Filling

12.  Schedule an appointment
 Plan what you will say
 Be prepared
 If second hand, obtain specific
examples and documented behavior
Before the Feedback Conversation

13.  What was effective?
 What could be done differently?
 Future strategies
 Do you need to document?
 Do you need help?
After the Feedback Conversation

14. • Incorporates the learner’s perspective
• Active and interactive
• Avoids assumptions or judgment
• Promotes lifelong skill of reflection
ASK TELL ASK

15. VideoVignette
Ask-Tell-Ask on YouTube

16. Vignette 1
The Patient
This is a 35-year-old patient who has had
a persistent cough for 3 months that began
with flu-like symptoms. She has been well
otherwise, and has come to the office
today to get a medication that will stop her
coughing.

17. Vignette 1
The Trainee
In last week’s New England Journal of
Medicine, I read an article recommending
chest CT scans for all patients with persistent
coughs. The article also pointed out that
cough suppressant should not be used until
the cause of the cough is fully elucidated.

18. Vignette 1
The Preceptor
Provide level 1, 2, and 3 feedback to the
trainee using the “Ask-Tell-Ask” approach.

19. Vignette 2
The Trainee
I have just examined a 13-year-old girl who has
had abdominal pain for 2 weeks. A full work-up in
the emergency room 2 days ago failed to reveal
any pathology. I did a brief history and a thorough
abdominal and back exam. I am confident that this
patient has a mild gastroenteritis, but I have
ordered a urinalysis to help confirm my impression.

20. Vignette 2
The Preceptor
Unfortunately, the trainee’s differential diagnosis was
incomplete. No screening questions for sources of
stress were explored even though the patient’s father
is an alcoholic and her parents recently went through
a difficult and bitter divorce.
 Provide level 1, 2, and 3 feedback to the student
using the “Ask-Tell-Ask” approach.

21. Summary
1. Provide feedback as soon as possible.
2. Focus your feedback on specific behaviors.
3. Provide Level 1 Feedback (only what you
observed the student do), Level 2 (your
reaction), and Level 3 (your prediction).
4. Use the “Ask–Tell–Ask” approach
5. Remember … without feedback:
a. Good performance is not reinforced.
b. Clinical competence is achieved empirically or not at all.
c. Learners feel adrift in a strange environment.

22. End with Ende
“The important things to remember about
feedback in medical education are that …
- it is necessary,
- it is valuable, and
- after a bit of practice and planning, it is
not as difficult as one might think.”
- Jack Ende, MD
Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781.

23. Remember to provide the three levels of
constructive feedback along with the
“Ask-Tell-Ask” approach with your learner.

24. What will you keep the same?
What will you do more of?
What will you do less of?
What will you stop doing?
What will you do differently and how will you do it?
What will you add?
LEARN – REFLECT -TEACH