Authors: Sean Dyer, MD; Geoffrey Comp, DO
Editor: Michael Gottlieb, MD; Teresa Chan, MD, MHPE

A Case

Kate is the program director for an emergency medicine residency and is scheduling the upcoming end-of-year reviews. She has received verbal and written feedback that John, a new intern, has been continuing to demonstrate a below-average knowledge base, and has been having a challenging time balancing an appropriate patient load as well as developing appropriate treatment plans on shift. 

Early on during the intern year, John struggled to keep up with other members of his class, and Kate had met with him for a mid-year evaluation. She discussed some of the comments she had received about his performance, and he seemed to react negatively toward the feedback. Kate tried to provide encouragement but was concerned that John has not made any changes to help him progress. This frustrates Kate as she took extra time and effort to help John but feels as though she wasn’t able to get through to him. 

Before the first feedback session, John felt he was on track for his level of training and was very surprised to receive negative feedback from the faculty. He felt defensive throughout the whole discussion and left the meeting frustrated, thinking that the faculty were unreasonable and were too judgemental. 

Kate had hoped that the session would inspire him to make changes but is worried that John will not progress adequately. She would like to have a more constructive end-of-year evaluation session with John to help him meet the potential she sees in him. 

Background 

Feedback is essential to a learner’s growth and continues to be an important area of study for medical educators.^3,4 Effective feedback can be used to help a new learner acquire or solidify new concepts. It has been shown to improve technical hands-on skills as well as patient communication, leadership, teamwork, and physician well-being.¹ While the importance of feedback is widely understood, high-quality, evidence-based recommendations for feedback are lacking.⁴

The authors of the R2C2 Feedback Model sought to create an evidence-based and theory-informed model for facilitating performance feedback.² The authors sought to address the existing challenges with feedback receptivity and using feedback to inform one’s self-assessment and performance improvement.⁵ Using theoretical frameworks and evidence from the literature, the team identified the following three components^2,6: 

1. Focusing on enhancing individual self-awareness and engaging with the learner through a humanist and person-centred approach;
2. Using an informed self-assessment approach that allows a learner to utilize external feedback to help generate an appraisal of their own performance; and
3. exploring the science of behavior change to enhance the incorporation of feedback.

Through these lenses, the group derived a structured method to “facilitate formal feedback and coaching conversations, enable collaborative discussions between supervisors and residents, and establish a safe environment through a series of open-ended questions that emphasize reflection and continual improvement.”¹

The authors tested the method and provided both objective and subjective supporting evidence of the benefits of successful implementation of the system. The group performed two studies across multiple sites and programs in graduate medical education, demonstrating that the R2C2 model was effective in engaging residents in a reflective and meaningful goal-oriented interaction.^3,7 The authors also developed and published an online tool kit comprised of templated handouts and video resources for implementation of the program.⁵

The authors surveyed educators and learners after implementation of an R2C2 session and identified three features that were most valuable in successfully providing and accepting feedback. First, the use of open-ended questions was reported to promote a respectful teacher-learner relationship, which was paramount in the success of the session. Second, the discussion was more effective when the content was oriented toward coaching and the learners use of assessment data. Finally, the goal of fostering teacher-learner collaboration assisted in the development of the learner’s goals and determination of areas for growth.³

Modern Takes on this Theory

Many of the techniques that Drs. Mann & Sergeant had introduced to the world via the R2C2 model overlap extensively with the key features of a number of findings in simulation debriefing. More recently, Dr. Sargeant has collaborated with a number of collaborators from the feedback and simulation debriefing world to attempt to coalesce two bodies of literature that have historically been quite disparate. This group have recent published a paper rebranding all of these post-learning encounters as Learning Conversations.⁸

Other Examples of Where this Theory Might Apply

A modified version of the R2C2 Feedback Model appropriate for shorter interactions has been described.¹ This allows for the teacher to still use the four stages as described above but in a shorter time period without losing the benefits provided by the model. This is a useful variation for teachers to ensure their feedback is given in the moment, instead of waiting until a mid- or end-of-year evaluation. While it was initially developed to guide a formal feedback session, a similar model can be used to help deliver feedback and provide coaching opportunities in real time. For example, an Emergency Medicine attending physician could use the R2C2 model at the end of the learner’s shift, rather than waiting until the end of the rotation.

Limitations of this Theory

The R2C2 Feedback Model has several limitations. One of the most commonly cited limitations in the initial articles was the time commitment. It requires a 30-60 minute meeting as well as time for the instructor to learn the technique and time for the learner to review their feedback ahead of time. These issues are partially addressed by the ‘in-the-moment’ modification discussed above. Additionally, in order to achieve meaningful feedback, the learner must be able to self-reflect on their performance and to discuss their reactions to the feedback. For  learners who have difficulty with this step, it might limit the quality of feedback and coaching acquired with this model

Returning to the case…

Kate was determined to lead a constructive feedback session with John and used the R2C2 Feedback Model to structure the discussion. She started the meeting by setting the stage and building the relationship by explaining the purpose of the feedback session as well as the review process. She asked if he had any other questions, and she was surprised to hear that John was very nervous about the review and didn’t know what he was supposed to learn from the process. John felt much more involved as Kate explained the review process as well as how the feedback was collected. 

Kate then asked John to review the on-shift feedback with her. She asked him about his initial reactions as well as if there was anything that was particularly surprising. John was initially visibly hurt and irritated when reading the comments. However, Kate was able to listen and affirm his reactions to the feedback. Ultimately, she discovered he had been wanting to improve some of the weaknesses that were being uncovered but didn’t know how to address them. 

By asking if there were any issues with the content of the feedback forms, Kate was able to help John identify that charting on shift was a specific area he wanted to improve. John felt that he was listened to and started to change his opinion of the conversation from a negative, accusatory interpretation to one of encouragement and constructiveness. 

Finally, Kate was able to help coach John by helping him identify one of his senior residents that he looks up to as a person to discuss charting skills. They also had an excellent discussion about some of the barriers John felt he needed to overcome in order to make the changes in his workflow. Both Kate and John left the meeting feeling encouraged by the discussion and optimistic for a positive change in John’s performance. 

References

1. Lockyer J, Armson H, Könings KD, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ. 2020;12(1):27-35.
2. Sargeant J, Lockyer J, Mann K, et al. Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2). Acad Med. 2015;90(12):1698-1706.
3. Sargeant J, Lockyer JM, Mann K, et al. The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use?. Acad Med. 2018;93(7):1055-1063.
4. Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What Is Known? A Scoping Review. Acad Med. 2017;92(9):1346-1354.
5. Sargeant J, Armson H, Driessen E, et al., Evidence-Informed Facilitated Feedback: The R2C2 Feedback Model. MedEdPORTAL. 2016. DOI: 10.15766/mep_2374-8265.10387
6. Armson H, Lockyer JM, Zetkulic M, Könings KD, Sargeant J. Identifying coaching skills to improve feedback use in postgraduate medical education. Med Educ. 2019;53(5):477-493.
7. Sargeant J, Mann K, Manos S, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017;9(2):165-170.
8. Tavares W, Eppich W, Cheng A, Miller S, Teunissen PW, Watling CJ, Sargeant J. Learning conversations: an analysis of the theoretical roots and their manifestations of feedback and debriefing in medical education. Academic Medicine. 2020 Jul 1;95(7):1020-5.