Start with either an open-ended question e.g. "How did things go with the last patient?" or a more focused question if you are working with the learner on a particular aspect e.g. "How well do you think you did on the history (or physical exam) on this patient?"

Most learners are pretty harsh critics of their own performance. They tend to immediately discuss their areas of weakness and frequently start strategizing how to improve. This allows the teacher to emphasize positives and give advice on improvements - not only a pleasant situation but also powerful and enduring adult learning as the learner is taking responsibility and "working it out" for themselves. Conversely, if the student has limited insights on their suboptimal performance, the teacher needs to provide a reality check on the expected level of performance. This is much better done as soon as you become aware of the issue than coming as a shock in the form of a poor evaluation at the end of the course.

A genuine comment on the positive behaviors encourages the learner to repeat them. This is especially true if you can link the behavior to a positive outcome e.g. "You took care to encourage the patient to explain why she had not been taking her medicine. Now we can work with her on finding cheaper alternatives". Positive feedback also has more impact if it is specific (not just "good job") and is reinforced, acknowledges changes made by the learner, or is part of an overall plan for improvement rather than just an isolated event. (e.g. "I was very pleased to see you using the techniques we discussed last week to put an anxious patient at ease.").

The message must be perceived by the learner that you can see specific ways to make them an even more effective clinician. The learner may have substantial insight. If the area you want to address was not volunteered by the learner, try a question such as, "If you could go back and do the patient visit again, what would you do differently and why?"

Feedback that is perceived as a demand to do things "only my way" will not succeed in the long term. Explain what needs to be changed and why to provide incentive to change. Often a demonstration is appropriate. Avoid blame or personal comments as these create barriers to change. Ensure that student is capable of making the change -- they may need more information (suggest readings or resources to help) or opportunities to practice a skill (e.g. suturing) - and express your confidence in them.

Finally, keep the level of training in perspective and don't overwhelm the learner by forcing too many changes at once or asking them to do impossible things. e.g. "Your histories are very complete but are taking a long time. I would like you to focus more on the presenting complaint and being ready to give me a concise presentation after 15 minutes....it takes practice!"

Consistency is essential for positive changes to become integrated into normal functioning. Acknowledging positive changes reinforces them and stimulates the learner's motivation to continue to become even more proficient in patient care. To help remember the basics and structure for your feedback, some experts suggest "serving the feedback sandwich":

• What was done well?
• What needs to be improved?
• How to make changes?

Remembering to ask for the learner assessment first ensures they are ready to digest the "sandwich" and follow-up verifies it provided benefit.

For those who like mnemonics, we found TOLD AS and IMPROVE as ways to remember the key aspects of feedback.

Feedback should be:

Timely (as soon as possible after the behavior)

Observed (based on your personal observations)

Limited (to a few items, not overwhelming)

Descriptive (expressed objectively as facts, not opinions)

Actions (concerns professional behaviors)

Specific (specific, changeable behaviors)

Giving effective feedback involves:

Identifying objectives clearly before the learning sessions

Making an environment that includes regular, constructive feedback (feedback-friendly)

Performance assessment (directly observed)

Responding to learner self-assessment

Objective, outcome-oriented, information on specific behaviors

Validating what was done well

Establishing a practical plan for follow-up and additional feedback

The bottom line for feedback:

• We work together to care for patients.
• You already do these things well.
• Here's how to make your patient care even better.
• I will keep working with you to become the best possible clinician.

Assessment is hard so preceptors can be tempted to procrastinate but this only makes the process harder. Just like completing patient records quickly keeps your recall fresh, "just do it."

Start by doing your homework. Read through the evaluation documents at the beginning of the course and check them periodically during the course to avoid the awkward situation of having to provide an opinion on something the learner did not do or about which you have very limited information.

If in doubt about what is expected, ask! Then orient your student at the beginning of the course, setting clear expectations so the student isn't surprised by their final assessment.

Short notes on specific items that occurred during the course and/or regular notes on the learner's progress can be invaluable memory prompts when completing the end of course assessment. A useful tool is the "Plus/Delta Card".

It occurs when a student is so nice and enjoyable to work with that evaluations are unreasonably high. This can also occur when a learner has a reputation for being "great" or has had superior grades on previous courses. To avoid the overall impression obscuring problems and falsely inflating grades, assess each item strictly on its merits.

Grades can also be influenced by negative reactions to a student, especially personal attributes or attitudes that don't fit with your practice. Call the course director early if you anticipate any difficulty in working with a learner or providing a valid, objective evaluation.

It is very important as it concerns how the learner performed in your practice environment but the course director typically includes input from other supervisors, written exams, etc., to determine the student's grade.

This can feel awkward but it is vital to your student's development as a physician. If you oriented your student clearly at the start and observed and gave effective feedback over the course of your interactions, then there should be no surprises. If you think your evaluation is harsh or has a lot of negatives, the reason may not be that "I am just a harsh evaluator" or even "I am not doing this correctly" consider:

You may be in the best position to detect significant negatives that are masked in other experiences: e.g. students with limited knowledge base can frequently "get by" on wards or faculty interactions but not in the office. The things you are perceiving may resonate with reports from other faculty members or evaluators: the course director needs objective input from multiple sources to validate concerns.

Conversely, if all your evaluations are superior and you seem to get only the very best students, consider:

Are you grading too highly? Check the criteria for scores and discuss your interpretations with the course director

Can you verify that the student consistently performs at the level of your assessment? Did you only see them on good days or do you only remember the positives?