October 10, 2012

360-Degree Feedback

by Andrea Passarelli, Pharm.D., PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Preceptors play an integral role in the development of pharmacists.  Most schools of pharmacy provide formalized training and education to their preceptors in order to help them master effective precepting techniques, but literature surrounding this topic is scarce.  Preceptors should use a variety of teaching strategies throughout a rotation and these should be tailored to the learner’s stage or professional development.1  As learners grow in their ability and confidence, they should be performing more tasks independently, such as medication reconciliation, discharge counseling, and "rounding" with the medical team.  In these situations, the preceptor might use an assessment technique known as 360-degree feedback to evaluate the student’s performance.  The 360-degree feedback technique generally involves the preceptor asking other healthcare professionals as well as patients about the student’s performance.  This evaluation technique is gaining popularity in healthcare and other sectors.  I wanted to research this technique further so that I could use this assessment strategy during my career.

One paper published by Joshi et al. in Academic Medicine described the successful implementation of 360-degree feedback for obstetrics and gynecology residents at Monmouth Medical Center.2 Residents were assessed on their interpersonal and communication skills by nurses, faculty members, allied health professional staff, medical students, patients, and co-residents.  In addition, each resident completed a self-assessment.  The researchers found good correlation between evaluations within each group of evaluators as well reasonably strong agreement among evaluators regarding each resident's rank among the peer group. Interestingly, there was a negative correlation between the rankings by faculty, staff, and medical students with the rankings given by peers.  The highest-rated residents (based on faculty, staff, and student evaluations) received low marks from their co-residents and vice versa.  This may perhaps be due to some perceived competition or a desire to “get ahead” by rating high-achieving residents poorly.  On self-assessment, junior residents typically rated themselves highly while senior residents rated themselves average or low.  This may have been because senior residents were setting higher standards for themselves or have increased self-awareness later in the curriculum. A potential advantage of 360-degree feedback employed at Monmouth Medical Center: evaluators were eager participants because their feedback was anonymous. The 360-feedback technique has been widely described in medical education journals, but has been most often been used in residency training rather than student education.3-6  360-degree feedback can be an extremely effective tool for a preceptor, as learners will often communicate differently in the presence of a preceptor and when independently communicating with peers, staff (who may be perceived to be at different social ranks within the organization), and patients.

When I was a student I had one experience with 360-degree feedback during my first acute care rotation.  On the last day of the rotation, my preceptor allowed me to round independently with the team.  After the team finished rounding, my preceptor asked the medical interns, attending physicians, and nurse case-manager about my performance.  In subsequent advanced practice experiences, both as a student and resident, preceptors have occasionally sought feedback from physicians regarding my performance.  But most based my evaluation solely on their direct observations.

While my experience with the 360-degree technique from the perspective of a learner is limited, I believe there are some important points that should be considered prior to implementation.  First, it is important to inform the learner that this technique will be used.  Although the goal is to assess the learner’s performance without influence from the preceptor, learners might be taken aback if their performance is discussed with other individuals without their knowledge.  Further, it is important for preceptors to remember that in order to effectively implement this technique they must ask a breadth of individuals (with different roles) to participate in the process.  This was done during my first rotation, but not in subsequent rotations as preceptors only asked physicians for their input.  I have never had a preceptor ask one of my patients about their perception of my abilities.  And with the notable exception of my first rotation, my preceptors haven’t asked medical interns, medical students, or nurses for feedback.

360-degree feedback appears to be an incredibly valuable assessment tool that can enhance the quality of evaluations provided to both pharmacy students and residents.  This technique allows preceptors to more accurately assess a learner’s communication skills, especially in the absence of preceptor supervision.  Research has shown that this is an effective and accurate evaluation technique when used in medical residency training, but its use has not (yet) been described in the pharmacy education literature.  Preceptors utilizing this technique should be familiar with its fundamentals, and should ask individuals in multiple roles, including patients, for feedback regarding the learner’s performance.  When used appropriately, 360-degree feedback allows the preceptor a unique opportunity to obtain a complete picture of the learner’s strengths and can help them identify areas for improvement.

1.    McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effective precepting. Am J Pharm Educ. 2006 ;70(3): Article 58.
5.    Sorg JC, Wilson RD, Perzynski AT et al. Simplifying the 360-degree peer evaluation in a physical medicine andrehabilitation residency program. Am J Phys Med Rehabil 2012; 91(9):797-803.

October 4, 2012

Taking the Fear Out of Feedback

by Connie Yoon, Pharm.D., Assistant Professor, University of Maryland School of Pharmacy

During my two years of residency training, I knew providing feedback to my preceptors regarding the rotation and their teaching behaviors was expected.  Yet for some rotations, this moment was filled with fear.  Fear that the receiver would misunderstand my intentions or that this may harm my relationship with this person.  Fear that what I said would be misused or turned against me.  Despite this fear, I provide them with honest feedback.  Why did I take the risk and perhaps face retribution? Because feedback is necessary for professional development and learning.  I consider feedback as an opportunity for quality improvement, not a reason for retaliation.  I should also clarify that while fear may be a roadblock to giving feedback, it is also a roadblock for those receiving feedback, particularly when the feedback is negative.1  Feedback is a two way street.  In a field where feedback is critical to facilitating education and patient care, it is important to review methods for delivering and receiving constructive feedback.

To begin, we must define feedback in the context of teaching and learning.  Feedback involves “a process to collect information to determine whether or not successful teaching and learning has occurred.”2  Feedback is “a commitment between teachers and students for academic and professional development.”3   It is an important tool used by successful teachers to make adjustments to the teaching process by identifying areas that are successful and those that require improvement.

Feedback is strongly associated with students’ perceptions of the quality of education.4  Therefore, as educators, we must consistently give and request feedback from students.  However, the unfortunately reality is that students are infrequently requested to provide feedback regarding the teacher’s performance (and typically only at the end of a course!).  Conversely, teachers do not provide feedback to students as often as they'd like.5  Moreover, teachers tend to have an inflated view of their feedback skills.  This was evident in a study published in 2008 by Sonthisombat.5  This study surveyed Pharm.D. students and preceptors to compare the perceptions of preceptors to that of students in regard to the preceptor’s teaching behaviors.  Survey items included rating the teacher’s frequency in giving positive feedback for good work, inviting comments or criticisms of the preceptor, discussing student strengths and limitations, and evaluating and advising students of their progress.  On nine of the 47 items, preceptors’ ratings were significantly higher than that of student ratings.  The majority of the preceptors perceived themselves as “well done and adequate” in terms of providing feedback to students, providing positive feedback, and responding positively to student’s comments and suggestions.  A significantly lower percentage of students rated their preceptors as well done and adequate in these areas, revealing a disparity between preceptors’ and students’ perceptions.  This study identified several areas for preceptor development and providing feedback was clearly a prime component. As educators, if we are committed to our students and the quality education of their education, giving constructive feedback is one thing we must learn to do well.

In order to fulfill this commitment, we must create an environment that encourages giving and receiving feedback.  There are several characteristics of constructive feedback.1-3  Feedback should be:
  • Relevant.  Address the teaching and learning performance objectives identified for the learning activity.
  • Objective.  Base feedback on facts or observations not on feelings. Keep comments impersonal as much as possible.
  • Individualized.  The goal of the feedback is to meet the needs of the student or teacher and enable the receiver to maximize their potential.
  • Helpful or informative. Provide suggestions for improvement.
  • Respectful.  Respect the student and/or teacher’s integrity and needs.
  • Confidential.  Do not involve intermediaries unless absolutely necessary.  Only the student and teacher should be involved in the feedback session.
  • Encouraging.  The student and teacher should be motivated by a desire to improve their learning/teaching methods.  This will can help to reduce the hostile emotions commonly associated with feedback that is negative.
In general, feedback is better received when given in a timely manner so that recipients have a opportunity to improve.  More frequent feedback makes each encounter less emotional and feedback becomes a common, routine part of the learning process.  Learning expectations for the activity should be articulated early to reduce ambiguities in performance objectives and minimize surprises during the evaluation.  Negative feedback should be balanced with motivational statements and positive feedback.  In order to maximize the potential use of feedback as a learning tool, both the deliverer and receiver of feedback should be receptive.  Solicit feedback and express appreciation when receiving it to model an accepting behavior.1  Most importantly, create an atmosphere of trust and respect when giving and receiving feedback.

Constructive feedback, given or received, plays a critical role in teaching and learning.  We should not allow fear to prevent us from employing feedback in our daily activities.  Providing feedback in a structured, constructive manner can help minimize fear and maximize its utility as an educational tool.

1.    Hunter TS. Giving and receiving constructive feedback in pharmacy practice. Drug Topics [Internet]. 2009 Jun 1 [cited 2012 Aug 30].
4.    Torres DM, Sebastian JL and Simpson DE. Learning activities and high-quality teaching: perceptions of third-year IM clerkship students. Acad Med 2003;78:812-814.
5.    Sonthisombat P. Pharmacy student and preceptors perceptions of preceptor teaching behaviors.  Am J Pharm Educ 2008;72(5):1-7

The Instructor’s Role in Group Work

by Eun-Young Lee, Pharm.D., PGY1 Pharmacy Practice Resident, Howard County General Hospital

Teamwork is relevant to my pharmacy practice and the skills I acquired as a student in group exercises in the classroom were critical for building the habits necessary for effective teamwork. Instructors, therefore, have an important role to assist students during group exercises.

Many educators agree that group work fosters social development, critical thinking, and problem solving skills.1,2   These skill sets are desired by many employers and can equip the students for their future career endeavors. There are several ways educators can guide students to work effectively as a team. The instructor should be actively involved in mentoring the groups while providing enough opportunities for autonomy for students to find their own resolutions and answers. Furthermore, there are several things instructors should consider when incorporating group assignments within a course.  Instructors should provide a clear purpose for each assignment and offer strategies to help address non-contributing students.

Providing a Clear Purpose of the Assignment

Instructors should help students understand the purpose of each assignment by clearly stating expectations, goals, and objectives of the group activity.2,3,5 Identifying learning objectives assists students to focus on what needs to be accomplished.

In addition, group assignments should purposefully cultivate interdependence.  Although the instructor is available to mentor students throughout the learning process, group projects should encourage student learning amongst their peers.
5 In other words, collaborators of a team can learn to depend on their group members. There are four types of interdependences:4
  • Goal interdependence: By achieving one common group goal, each individual believes he or she is able to fulfill his or her own goal.
  • Reward Interdependence: Good performance of the entire group leads to a reward, such as a good grade.
  • Role interdependence:  Each member has a specific role and function to fulfill within the group.
  • Resource interdependence: Each member has specific resources or knowledge that must be contributed.  One person does not have all the resources to complete the task independently.
Interdependence in group assignments is critical. Healthcare providers within multidisciplinary teams depend on interdependence to provide the best treatment for patients.  This requires various health care workers to coordinate and contribute knowledge according to their specialty.

Addressing Problems Related to Non-Contributing Students

Ideally, each member should equally participate, but many groups face the problem of social loafers.1 Educators should be aware that there are two types of non-contributing students, a struggler and a social loafer. Students categorized as strugglers have difficulty participating due to a lack of knowledge or are marginally behind in their understanding.1 Loafers on the other hand, can be characterize as “free-riders” who make little effort to contribute to the group’s work.1

Both types of non-contributing students may be mistakenly viewed as loafers.  However, approaches to assisting loafers versus strugglers are different.  Struggling students may benefit from supplementary support from the instructor.1 Conversely, a loafer needs a different approach. Strategies such as using peer assessments, keeping individual diaries, and retaining logs of online cooperation may be applied to monitor participation.1 These strategies allow contributing members to successfully complete their assignment without being hindered by the slackers.1  Social loafers should receive feedback from their group and this may correct their behavior to fully participate.1 A downside to confronting an inactive student by the other group members may lead to the alienation of the loafer or exclusion altogether. Usually, groups are able to resolve this problem without the instructor’s intervention.1

Instructors should define loafers and strugglers prior to assigning the project to the class.  This allows team members to identify and address the issues of loafers and strugglers differently.  Also, instructors should provide counseling to remind students that everyone in the group possess different levels of skills and contribute in different ways.1 This allows the students to recognize that individuals who initially struggle may become highly effective participants once their skills are developed.1 Additionally, instructors should encourage students to assign roles that best suit their expertise or skill level. Thus, I believe that allowing opportunities for all students to contribute will build confidence and allow students to thrive in group settings.


Group assignments offer students opportunities hands on experience to develop teamwork skills. This begins with providing groups with clear instructions to help them understand the purpose of the assignment. Inevitably, during collaborative work, members of the group may face conflicts and issues.  Instructors should utilize strategies to facilitate both contributing and non-contributing students.  This allows groups to achieve a common goal, while giving them enough autonomy to solve problems on their own.

Overall, I believe there are several advantages of incorporating group work into classroom-based courses. Being able to contribute effectively as a team member is a desirable skill employers value.  As a student, I had many opportunities and I am grateful to have worked within many groups with different dynamics.


1.  Freeman L, Greenacre L. An examination of Socially Destructive Behaviors in Group Work.  The Journal of Marketing Education. 2011; 33: 5-17.

2.  Burke A. Group Work: How to Use Groups Effectively. The Journal of Effective Teaching.  2011; 11: 87-95.

3.  Group Work. Bloomington: Indiana University; 2011. [cited 2012 Sept 7].

4.  Colbeck CL, Campbell SE, Bjorklund SA.  Grouping in the Dark:  What College Students Learn from Group Projects.  The Journal of Higher Education.  2000 Jan/Feb; 71: 60-83.

5.  Atwood A, Klurfeld A, Kotker J. Using Group Work Effectively: Graduate Student Instructors Teaching and Resource Center. [Internet]. Berkley: University of Berkeley; 2012 Jan 30. [cited 2012 Sept 10].

Creativity, not conformity

by Martin Bishop, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, the Johns Hopkins Hospital

Sir Ken Robinson, an author and advisor on educational reform, has worked on educational projects in the United Kingdom since the 1980s.  He considers the traditional strategies and methods of education stifling to the creativity of children and students.1  This lack of creativity can limit the effectiveness of graduates as they progress to their careers.  He argues the hierarchy of subjects within our formal educational systems in most countries favor mathematics, science, and languages.  This emphasis undervalues the humanities, music, or dance.  It makes sense that the modern educational system, which came to being during the rise of industrialism, would favor educational topics that provide jobs in an industrialized society (“Don’t do music, you’re not going to be a musician; don’t do art, you won’t be an artist”1).  But creativity can be defined as more than art, dance, or musical talents.  Creativity in education can be related to the ability to solve problems and think critically by using old and familiar ideas adapted to new situations.2  By not emphasizing and fostering creativity, student learn by memorizing facts and key words to regurgitate them on a cumulative final exam.

According to Sir Robinson, “our education system has mined our minds in the way that we strip-mine the earth: for a particular commodity…and for the future, it won’t serve us.”  It is unfortunate that society values students who become physicians, lawyers, and bankers instead of appreciating a diverse arrangement of professions that suit personal interests and passions.  Moreover, the needs of the future economy of the United States (and the world) may be best met by a community of highly engaged professionals with various skills sets including firefighters, historians, artists (just to name a few).3 Robinson equates the educational system to fast food preparation or an industrial production line where curricula and assessments are standardized.3 The answer to the future of education, according to Robinson, is a personalized curriculum with external support where the student can develop at their own pace and focus on their strengths and deficits.3  There is growing support for the strategy of personalizing or individualizing instruction for students.  One example supported by Bill Gates (of Microsoft) and Eric Schmidt (of Google) is Khan Academy founded by Salman Khan.

An individualized education for each student

A traditional class consists of lectures, then homework, followed by an exam. Based on the results of the exam, the students earn a grade and the class then moves on to another topic or another subject.  If the student earns a 70% or higher, they get to move on to learn other things.  But what about the 30% (or less) of the material that was missed on the exam?  In this model, that missed material (concepts, ideas, facts) are perhaps lost forever.  In his TED presentation, Salman Khan uses an analogy of learning how to ride a bicycle to illustrate this concept.  If you are learning how to ride a bike, you might be able to mount the bike, pedal, turn, and ride in a straight line …  but perhaps you haven’t learned how to stop.  You crash into things or just fall and injure yourself all the time.  At this point, having mastered 70% of what’s expected, you would receive a passing grade and proceed on to unicycle!4  But you haven’t really mastered how to ride a bicycle yet!  I would occasionally ask myself about that lost knowledge during my higher education (“Well, what did I miss?”) and would often be denied the chance to review my exam so that I could learn from my mistakes.  Ideally, students should truly master each topic before moving on.

The vision of Salman Khan’s Khan Academy is to encourage each student to be accountable for his/her own learning.  He encourages student to view recorded lectures (which can be repeated as needed) at home prior to class.5  In this setting, students are allowed to fail without punishment or consequences, until they are able to master a specific task.  When used in conjunction with live classes, the student can access online modules and then engage in problem solving projects with their peers facilitated by an instructor.  In this setting, the instructor is acting as a mentor or coach rather than a lecturer.  For the students who are struggling with a specific task (which is shown graphically and in real-time to both student and instructor), the instructor can focus his/her effort on small cohort of students to maximize efficiency of time and effort.  Additionally, the Khan Academy uses the data (reportedly over 191 million lessons delivered)6 to improve modules for future students.  This software and website promise to revolutionize the way classes are taught.  The Khan Academy approach has already been implemented in classrooms in Los Altos, California.6  While Khan Academy has presentations and modules for primarily aimed at K through 12 student, it could be adapted to very complex topics in higher education including medicine, engineering, or history.  It is worth noting that these strategies do not foster mastery for all students.  Just as some students learn better from visual presentations or modeled behavior, only some students will fully embrace instructional video lectures.

I would aspire to bring some of these ideas and strategies to the education of pharmacy students in my present and future career.  Ideally, an approach including an element of course personalization would more effectively learn concepts.  Although a pharmacy school with a less rigid curriculum (i.e. P1 classes, then P2 classes, etc.) and increased flexibility may be years away, we should work towards this goal by making course materials available for all students in the school before and after enrollment in a course.  Although the classes and exams could still be structured in a traditional manner, at the very least lectures and exercises from the course should be open for anyone to visit or revisit.

1.    Sir Ken Robinson. Ken Robinson says schools kill creativity. TED: Ideas worth spreading. Published February 2006. Accessed September 20, 2012.
2.    Ferrari A, Cachia R, Punie Y. Innovation and creativity in education and training in the EU member states: fostering creative learning and supporting innovative teaching.  Joint Research Centre – Institute for Prospective Technological Studies (IPTS).  Published October 2009.  Accessed October 1, 2012.
3.    Sir Ken Robinson. Bring on the learning revolution! TED: Ideas worth spreading. Published February 2010.  Accessed September 20, 2012.
4.    Salman Khan. Salman Khan: Let’s use video to reinvent education. TED: Ideas worth spreading. Published March 2011.  Accessed September 20, 2012.
5.    CBS News. Khan Academy: School of the future. 60 Minutes. Published September 2, 2012.  Accessed September 20, 2012.
6.  About Khan Academy. Khan Academy. 2012.  Accessed September 22, 2012.