Questions about feedback

Answer to "How can health professions educators develop trusting relationships with learners when the educators have fragmented (rather than longitudinal) interactions with learners?"

Research indicates that  respectful working relationships between teachers and learners in which the teacher demonstrates sincere interest in the learner’s development enhance the perceived credibility of feedback data. When feedback is viewed as credible, it is received, accepted and incorporated into performance, potentially leading to behaviour change. Newer models of feedback prioritise trusting relationships / alliances between feedback providers and recipients as a facilitator of meaningful feedback conversations. Unfortunately, many clinical rotations are very short and do not allow for relationships to form and mature. In fact, working relationships may only last a day or two in procedure or skills-based specialities and teachers need to pay attention to forming trusting working and learning relationships within a short time while also focussing on the skills to be learned.


Using the therapeutic alliance as a model, Telio et al proposed an “educational alliance” framework to construct feedback conversations. Forming an alliance with learners would allow educators to develop a more meaningful understanding of the context of learner performance and provide specific and useful feedback. Sargeant and Holmboe have emphasised that feedback is a reflective conversation with learners to help their professional improvement. To accomplish this effectively, teachers should use coaching strategies to form an educational alliance and collaboratively create an action plan. In their framework, they recommend that teachers observe learners directly to gather objective data, assess performance in comparison to a standard or expected outcomes, engage learners in feedback covnersations, encourage learners to use feedback data for performance improvement, evaluate the impact of the action plans and then reenter the cycle through observation of performance again. Coaches facilitate self-directed learning through questioning, active listening and appropriately challenging learners within a supportive learning climate.


We propose a participatory design loop for feedback conversation based on a trusting alliance and comprising:

  • establishment of goals by learners and teachers

  • direct observation of performance by teachers

  • feedback conversation that includes facilitated self-reflection through use of open questions

  • creating learning / work opportunities to incorporate feedback and change behaviour

  • debriefing of new performance

  • re-entering the cycle through discussion of new goals by teachers and learner




Ramani, S., Könings, K. D., Ginsburg, S. and van der Vleuten, C. P. M. (2018) ‘Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships’, Medical Teacher.

Rich, J. V. (2017) ‘Proposing a Model of Co-Regulated Learning for Graduate Medical Education’, Academic Medicine, 92(8), pp. 1100–1104.

Sargeant, J. and Holmboe, E. (2017) ‘Feedback and coaching in clinical teaching and learning (chapter 13)’, in Practical Guide to the Evaluation of Clinical Competence. 2nd edn. Elsevier Health Sciences, pp. 256–269.

Sargeant, J., Lockyer, J. M., Mann, K., Armson, H., et al. (2018) ‘The R2C2 Model in Residency Education:  How Does It Foster Coaching and Promote Feedback Use?’, Academic Medicine, 93(7), pp. 1055–1063.

Sargeant, J., Lockyer, J., Mann, K., Holmboe, E., et al. (2015) ‘Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2)’, Academic Medicine, 90(12), pp. 1698–1706.

Telio, S., Ajjawi, R. and Regehr, G. (2015) ‘The “Educational Alliance” as a Framework for Reconceptualizing Feedback in Medical Education’, Academic Medicine, 90(5). Available at:

Telio, S., Regehr, G. and Ajjawi, R. (2016) ‘Feedback and the educational alliance: examining credibility judgements and their consequences’, Medical Education, 50(9), pp. 933–942.