when i say When I say . . . feedback Rola Ajjawi1 & Glenn Regehr2 Feedback is a controversial topic in medical education. Both students and staff say they value it. Yet students often complain that they don’t get enough feedback and suggest that it is done to rather than with them,1 whereas staff report providing feedback at higher volumes than students perceive and claim that their comments are more valuable for learning than students appreciate.2 In part, these discrepancies in learner and teacher reports may be a result of students failing to notice feedback or educators misreporting the frequency with which they offer it.3 However, another possibility is that learners and educators have different definitions of what feedback is. Importantly, such ambiguities exist not only in educational practices, but also in the literature. Thus, the purpose of this paper is to explore what we mean when we say ‘feedback’. In informal conversation, the term feedback is used to describe a wide variety of phenomena: naturalistic consequences in the clinical environment (a patient’s condition worsening might be feedback that one is on the wrong diagnostic track); summaries of one’s clinical practice patterns or patient outcomes; marks on a test; 360 evaluations collected from colleagues and patients; corrective advice about how to hold a scalpel; written comments about performance; a stated judgement about how one did on a task; a conversation with an educator about how a particular task could have been done better, and a conversation with a colleague about one’s attitude or comportment in the clinical setting. All of these examples of ‘feedback’ indeed offer information about performance and provide an opportunity for 1 Centre for Research in Assessment and Digital Learning, Deakin University, Geelong, Victoria, Australia Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada 2 correction, fine tuning or perhaps reassurance. Yet to lump all these experiences into a single category may create conceptual confusion, leading not only to differing opinions of when feedback has occurred, but also to misunderstandings of what it is to engage in feedback well. Formal definitions of feedback also range widely. For example, tutor-centred transmission-oriented models describe feedback as the information given to a learner with the intent of improving performance.4 Student-centred process-oriented approaches define it as the processes through which learners obtain information about their work in order to generate improvements.5 More sociocultural perspectives on feedback argue that it is an act of meaning making of performance-relevant information along a learning trajectory.6 Thus, at one end of the spectrum, feedback is limited to information or data, delineated by role and positioning of the ‘provider’ and ‘receiver’. The other end may refer to any activity that demands active engagement from the learner to seek, interpret and judge information. All intend learning, growth and improving the quality of work. Yet the phenomena and concepts associated with this effort are so varied that the term feedback runs the risk of becoming meaningless. Thus, it may be helpful to find terms that draw distinctions between naturally occurring cues, data delivery, corrective teaching, recommendations for learning and feedback. We suggest that in educational parlance, the term feedback should be reserved for a dynamic and coCorrespondence: Rola Ajjawi, Centre for Research in Assessment and Digital Learning, Deakin University, 727 Collins Street Tower 2, Level 13, Melbourne, Victoria 3008, Australia. Tel: 00 61 3 924 43824; E-mail: rola.ajjawi@deakin.edu.au Medical Education 2019: 53: 652–654 doi: 10.1111/medu.13746 652 ª 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2019 53: 652–654 When I say constructive process in a shared social or cultural space. To elaborate this notion, we borrow from Reusser and Pauli,7 who state that two tenets are central to co-construction: ‘. . . solving the problem collaboratively, and constructing and maintaining a joint problem space. Both activities require constant negotiations and recreations of meaning’ (p. 914). All sides should have opportunities to reconstruct their knowledge and reframe practice during feedback. A shared understanding or solution needs to be developed that neither party possessed before. This requires a conscious and deliberate effort enacted through dialogue.7 This shift in emphasis can be seen in feedback approaches such as the ‘Relationship, Reactions, Content, Coach’ (R2C2) model8 and the educational alliance.9 Both construct feedback as collaborative conversations performed through a set of complex social interactions influenced by those involved, as well as by the relationship, culture and context in which the interactions occur. The educational alliance, for example, consists of three key aspects: (i) having a shared sense of goals, (ii) shared activities, and (iii) a bond.9 These are mutually constitutive in the sense that the process of constructing goals and activities leads to a recognition of positive intent and a strengthening of the bond, and reciprocally, a strong bond promotes learners’ engagement in behaviours such as feedback seeking, reduced avoidance and willingness to disclose10 even in brief encounters.11 phenomena that they should not be lumped in with the co-constructive process that we wish to reserve for the term feedback. By drawing such distinctions, we would hope not only to help researchers clarify and specify the range of mechanisms that might (or might not) induce change in learners, but also to encourage educators to attend to and hone the pedagogical processes and relationships that might more effectively support learners’ engagement in change. Thus, when we say feedback we are referring to a dynamic and co-constructive interaction in the context of a safe and mutually respectful relationship for the purpose of challenging a learner’s (and educator’s) ways of thinking, acting or being to support growth. This definition eliminates many of the events, objects and practices that might otherwise be labelled as feedback. For example, the provision of static information, whether in the form of grades, ratings or written comments, is not feedback because such information does not (cannot) dynamically engage with the learner. As with naturalistic cues, such information is merely available for the learner to interpret (or ignore) as the learner chooses. Moreover, feedback is not about an educator justifying grades or comments, which may be interactive, but is usually an exercise in reasserting previously delivered data rather than a coconstructive process. We are not asserting that naturalistic cues, delivery of data or argumentation (such as ‘justifying the grade’) are of no value to learning, merely that they are sufficiently different Finally, we would note that co-construction is an inherently fragile process and cannot be prescriptive. We have suggested potential ways forward through dialogue and positive regard, but we reject the idea that there is a set of mechanistic steps that can be followed to ‘do it right’. Further, although we have focused on the educator–learner duo in this article, we do not believe that feedback is only limited to these interactions. Thus, feedback may involve peers, patients or others, and there are likely to be many ways to enact it well. But we strongly suggest that, regardless of the who or how, the principles of co-construction in the context of a meaningful relationship must apply for it to be called ‘feedback’. At the same time, we would not wish our definition to be interpreted as advocating that feedback should be free of challenge, or even conflict. Indeed, working from an educational alliance frame, both parties commit to maintaining mutual respect for each other, distinguishing between the behaviour and the person. For this reason, praise and reassurance are important for establishing and re-establishing an educational alliance. However, if the supervisor is truly engaged in the alliance and cares about the learner, then the educator must also be committed to challenging learners in ways that help them become the practitioners they are striving to be. Thus, a demonstration of positive regard is not the feedback, but rather is a mechanism to establish and affirm the educational alliance within which difficult conversations may occur to leverage change. Developing the alliance through praise and support without offering challenge is not feedback, but mere tokenism. 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