Introduction
Although feedback is an integral aspect of work it can also be associated with anxiety, with one in four people reporting dread at receiving feedback more than anything else in their workplace.1 Several factors contribute to feedback anxiety, including fear of being judged, feelings of vulnerability, negativity bias, concerns about potential impacts on job security perceived competence, career progression, and fear of exclusion.1–4
Feedback in medical and surgical residency training has also been shown to provoke anxiety.5–7 Surgical residents face unique challenges related to feedback because they work in a high-pressure environment where performance deficits can have serious consequences. As such, they are at a high risk of feedback anxiety, especially when it’s negative.7,8
One of the key triggers that contribute to the negative emotions associated with feedback is what Stone and Hein1 refer to as “relationship triggers” which focuses on the person delivering the feedback. The perceptions of the receiver about the qualifications and the character of the feedback giver and the dynamics of their previous interactions become very important. Trust and rapport can influence how feedback is perceived and received.
Furthermore, provider bias can impact feedback when it is shaped by the life experiences, cultural background, values, assumptions, and style preferences of the feedback provider.9,10
The multicultural nature of our society has created an exciting educational context with an increasingly diverse cultural background. However, a lack of attention to the cultural factors in the feedback processes has been linked to feedback dissatisfaction in multicultural universities.11 The intercultural dimension of feedback in medical and surgical residents in the United States has not been explored. Furthermore, the current feedback approaches in surgery are “one-size-fits-all”, at a time when our general surgery residents come from various cultural backgrounds.
Our study examined the perspectives of surgical residents on the feedback they receive, with a particular focus on feedback anxiety and the cultural component of their feedback approach.
Methods
From February to June of 2023, we conducted 3 voluntary 45-minute focus groups consisting of a total of 23 surgical residents of post-graduate years 1, 2, 3, 4, and 5. Participating residents were rotating at the VA Boston Healthcare System from 3 affiliated academic training programs: Boston Medical Center, Brigham and Women’s Hospital, and Lahey Hospital and Medical Center.
Focus groups were conducted using 5 open-ended questions (Table 1) that were pilot tested with residents not involved in the study.
With participant permission, focus group sessions were audio-recorded. Transcripts were created from the audio recordings. All identifiers were removed. De-identified transcripts were then manually analyzed using open coding to develop thematic categories.
This study was reviewed and deemed exempt by our Institutional Review Board. When invited to participate, residents were reassured that their decision to participate in the study and their discussions would be de-identified and would not be used in their resident performance evaluations.
Results
Demographics
A total of 23 surgical residents participated in the study. The number of participants in each focus group ranged from 6 to 9. The demographic characteristics of the participants are shown in Table 2.
Qualitative Analysis
A total of 4 themes were identified, each with several sub-themes. The themes were: feedback quantity, feedback quality, feedback anxiety, and interventions recommended for improving feedback.
Feedback quantity
All residents considered feedback a crucial source of learning and growth and acknowledged that there has been an increased focus from their attending surgeons and residency programs on providing more feedback. While some residents appreciate receiving more, others report feedback “overload” and feel that they are being “watched all the time”, making them “worried about making any mistakes” and inhibiting their “autonomy and growth”. All residents agreed that the “focus should be more on the quality than the quantity of feedback.” (Table 3).
Feedback quality
While residents appreciate that the feedback feels supportive and is given in a timely manner, they were mostly critical of the quality of the feedback they receive. Residents consider that the feedback they receive often is not preceded by setting clear expectations beforehand, is not specific enough, is not actionable, and does not include specific strategies for improvement. Some also feel that feedback is often subjective, leaving room for favoritism. Feedback given on personality was considered biased against female residents.
Residents with different cultural backgrounds feel that the feedback lacks cultural sensitivity, as often the feedback provider interpreted a given situation not from raw observations but from a perspective based on their own values and culture without taking into consideration the residents’ culture. (Table 4).
Feedback anxiety
Most residents (17 out of 23) reported feeling anxious before and during formal feedback. Surgical interns, undesignated preliminary residents, female residents, international medical graduates (IMGs), and residents with a non-US cultural background reported experiencing more often anxiety about critical feedback, that they feel has affected their confidence, motivation, and performance.
Residents report less anxiety when receiving feedback from their peers, mentors, attendings who they know well, and from those who share common demographic characteristics (“look like them”). (Table 5)
Interventions recommended for improving feedback
Participants suggested several interventions for improving feedback (Table 6). At the resident level recommendations included education on managing feedback anxiety, receiving feedback, and understanding the cultural dimension of the feedback. For faculty providing feedback, some recommendations included education on how to give negative feedback, avoid feedback overload, provide observable feedback and feedback follow-up, and understand the cultural aspects of the feedback. At the program level, participants recommended providing the residents with the option of choosing the faculty giving formal feedback, involving peers in the feedback process, involving mentors of residents for important critical feedback, and providing faculty with cultural mentors to better prepare them for the cultural dimension of the feedback.
Feedback simulation involving both residents and faculty was recommended as one method to improve the feedback process.
Discussion
Our study showed that while all residents considered feedback a crucial source of learning and growth, they reported feeling anxious before and during formal feedback. We found that surgical interns, undesignated preliminary residents, female residents, IMGs, and residents with a non-US cultural background experienced more often feedback anxiety.
Evidence suggests that what these categories of residents might have in common an increased overall pressure and anxiety in their training. For instance, transition from medical school to residency is associated with cognitive overload and with high levels of anxiety,12 with surgical interns being most likely to fear hurting a patient or being “in over their head.”.13 Compared to their categorical counterparts, undesignated preliminary surgery residents (most of them being IMGs) often feel stressed, unprepared, and less satisfied with their operative experience, mentoring, and the “costs of training”, uncertain about their future career path, and under immense pressure to perform well.14–16 Female residents also experience significant bias, stress, and burnout during training leading to higher attrition rates.17–20 In fact, female sex has been shown to be the independent factor most strongly associated with residency attrition.21
Non-US born IMGs face additional, unique stressors during residency training such as a lack of familiarity with the US medical system and overall healthcare culture, bias, the perception of not being adequate, linguistic and cultural barriers to providing patient care, visa status and fluctuating immigration laws, and overall cultural adaptation.22–26
Importantly, psychology studies have shown that individuals experiencing anxiety are more prone to negative outcome evaluation and outcome expectancy than non-anxious individuals, leading to more feedback anxiety.27,28 With increased stress and anxiety during their training, it is not surprising that these groups of residents are more anxious about feedback. Therefore, residency programs should improve the support for these residents to address their stressors during training, so no residents are left behind.
Our study also showed that participants with different cultural backgrounds perceived that their feedback lacked cultural awareness and felt that the providers filtered their evaluations based on their own values and culture.
Hofstede’s 6-dimensional model of cross-cultural psychology29 provides context for the role of culture in pedagogical practice. These 6 dimensions include individualism vs. collectivism, power distance (strength of social hierarchy), uncertainty avoidance, masculinity vs. femininity (task-orientation vs. person-orientation), long-term vs. short-term orientation, and indulgence vs. restraint.29
Specifically, individualism, power distance, and uncertainty avoidance play critical roles in a student’s perception of feedback. For example, a resident from a culture with large power distances and weak uncertainty avoidance may respond better to direct feedback from an older mentor, than to feedback from someone they may view as a peer. However, residents from cultures that tend to be more nurturing may benefit from more ambiguous and indirect feedback.30 For feedback to have its strongest impact on residents, both the resident and the preceptor must display intercultural competence. This means that both parties must display openness, respect, and curiosity for the other’s culture while also being reflective and understanding of their own.11
Feedback is a valuable tool utilized for education, but the feedback process may look different from culture to culture.31,32 Additionally, culturally aware feedback provides room for reflection on the influence of systemic and institutional bias on the current healthcare system and healthcare education. Two-way feedback, which was recommended by the residents in our study, provides room for discourse that may challenge internalized bias unknowingly held by educators.33 With cultural diversity playing an increasingly significant role in modern day healthcare,34–36 cultural awareness is an integral element that must be considered by educators when providing feedback to residents.
Our study has several limitations. First, residents who agreed to participate in our study may have been more dissatisfied with their feedback and as a result more interested in improving the feedback process, introducing a risk for selection bias. Second, our study could also be subject to social desirability bias, with respondents answering questions with positive and favorable responses to be better received.
Third, the sample size is small, although in line with other focus group studies on surgical education and wellness. However, the study groups were diverse and from two different training programs. Fourth, our study cohorts included surgical residents from only three residency programs in the Boston area, and as such, our results may not be generalizable to all surgery residents nationwide.
Fifth, due to the qualitative nature of focus group studies, we cannot exclude inherent researcher bias as well as moderator’s influence on group discussions. To reduce these, we used structured questions and minimized moderator activity. Finally, to maximize anonymity the present study does not include information on individual residency program characteristics.
These limitations notwithstanding, our study brings awareness to the need for optimizing the feedback that surgical residents receive. This study additionally identifies several resident-recommended interventions for feedback improvement that should be considered by surgery residency programs.
Conclusions
Despite feedback improvements, surgery residents continue to experience feedback anxiety and feel that cultural sensitivity of the current feedback approaches is lacking. Institutional support from residency programs and input from residents are necessary for the implementation of educational interventions to reduce resident feedback anxiety and train feedback providers to increase their cultural awareness.
Disclosure Statement
The authors have no conflicts of interest or financial disclosures to declare.