The pitfalls and perils of anonymous learner feedback

‘Dr. [A] was late one minute, one time. But to be fair, it didn't negatively impact my learning’. This is a comment from a learner on my colleague's anonymised student evaluation of teaching form. The consideration of whether this might be a ‘fair’ comment is reflective of a larger conversation about the utility and value of online, anonymised feedback forms. As such tensions garner a heightened focus in health professions education (HPE) specifically,¹ the article by Jenq et al.² is particularly timely.

Their study offers an important contribution to this area of scholarly work as it compares both givers and receivers of feedback, offering a useful juxtaposition of challenges while most studies focus on one group or the other. Viewing both sides of the same coin in one context helps to illuminate the perspectives of multiple players in the clinical learning environment on the topic of upward feedback. Another distinctive aspect of their work is that the authors examine upward feedback in a Taiwanese culture, with speculation that learners and faculty in Asian cultures are more sensitive to power dynamics than those in Westernised cultures, thereby making in-person feedback conversations more difficult to hold successfully.

The authors found that the influence of medical hierarchy was prevalent and posed a barrier to giving and receiving feedback across all participant groups which included medical students, residents, nurses and clinical educators. For example, nurses were often prevented by their departments from giving feedback to clinical educators and felt as though their feedback would be ignored by clinicians. Learners were reluctant to provide constructive feedback for fear of retribution and concern that their feedback would also be dismissed due to their low status. Educators were more likely to accept feedback from more senior clinicians than from their learners or peers. Further, clinicians took constructive feedback particularly hard because they felt reputational consequences in front of others. Because of these strong and persistent power and social dynamics, the authors leave us with three implications for their work, each of which are deserving of their own respective ‘unpacking’.

The authors first recommend a shift to anonymous upward feedback processes with the hope that learners can give, and teachers can receive, constructive feedback without the threat of hierarchical issues that come with face to face conversations. It is important to keep in mind, however, that anonymous feedback comes with its own challenges. For example, feedback should be timely,³ but to maintain learner anonymity, feedback has to be held until long after the teaching encounter. Anonymous feedback mechanisms violate other foundational feedback tenets as well, by not being situated in an educational alliance, and with no opportunities for discussion and reflection,⁴ thereby sparking questions of whether anonymised ‘feedback’ should be considered feedback at all. It is also worth emphasising that anonymity is not a panacea for side-stepping power dynamics. Even when anonymised, perceptions of safety remain in the eye of the beholder, and some learners remain cautious, especially if they already feel marginalised or easy to single out in comparison with their peers.⁵ These worries may persist in an anonymised system, particularly in a culture where hierarchical considerations are so deeply entrenched. Given their own respective limitations, there is a place for both face to face and anonymous approaches, and we must be careful not to swing the pendulum too far by prioritising one approach and neglecting the other.

The second implication is that we should train students to give feedback. There is definitely a place to support learners in their effort to give feedback given that they are most often not trained in this regard. It is also important, however, not to solely view suboptimal feedback as a problem of competence. There are many barriers facing learners in their pursuit of offering meaningful feedback.⁵ For example, while we know good feedback should be specific, learners have to balance specificity with the risk it brings of being identified. We also know that feedback should be detailed, but learners are busy keeping up with their demanding academic and clinical schedules and, therefore, may forego giving detailed feedback in an attempt to manage their own cognitive load and well-being.⁵ Learners also worry about social implications as even providing positive feedback to their teachers yields concern that they might appear overly sentimental, thus harming their relationships.⁵ Therefore, vague or otherwise, suboptimal feedback is not merely a learner issue and cannot be solely resolved through upward feedback training.

Finally, the third implication is to provide guidance for faculty in receiving feedback on their teaching. While this is likely to be beneficial, making claims that ‘faculty development is needed’ merely scratch the surface and do not offer clear guidance regarding what specific resources and support might be needed.⁶ What could such a faculty development programme look like? There are a number of possibilities. For example, supervisors of teachers could support faculty through a facilitated discussion where teachers can reflect on difficult feedback and grapple with it. Peer-observation programmes where teachers observe each other and give feedback on their teaching can remove the threat of power dynamics. Encouraging teachers to model effective delivery of constructive feedback to learners and explicitly welcoming it in return can create an opening for leaners to do the same. There are surely other examples of faculty development initiatives, and programmes would benefit from considering which might work best in their own contexts.

In sum, HPE programmes across the world are lucky to have dedicated doctors who go above and beyond their professional responsibilities to teach well. Whether or not they have formal teacher training, such teachers are often reliant on student feedback to help them improve. While we can do our best to optimise pathways for learners to give feedback, at the end of the day, the culture of medicine makes the delivery of constructive feedback difficult—both anonymously and in conversations. Because of this, it is prudent for us to remember that supporting the development of teachers does not (and should not) fall on the shoulders of learners.⁷ I am, thus, grateful to the authors for casting an eye on these dynamics and thinking about how we might improve processes in varying cultural environments.