AMA Journal of Ethics^®

Peer feedback is a crucial component for any effective work environment, but it is particularly important in the medical setting where teams of clinicians often work together without clearly defined tiers of authority. Unlike businesses, where employees can expect to receive consistent feedback from CEOs and other supervisors, many physicians operate without superiors on hand to critique their day-to-day performance. Feedback via continuing medical education and evaluations from hospital administrators is, in itself, insufficient. While physicians may question the value of comments from those without perceived superior expertise, peer feedback is a valuable learning tool that should be added to the existing review system so that clinicians can learn to rely on one another to provide constructive critiques and guidance.

Despite the need for it, peer feedback in medicine is a rare practice that is associated with numerous fears and anxiety. The negative impact of little or ineffective peer assessment is 3-fold: it affects patients, clinicians, and the medical field as a whole. There are systems in place to review severe, adverse patient outcomes. But if the consequences of the mistake are minimal, fears of giving and receiving critical peer comments can prevent physicians and medical students from knowing about and learning from their mistakes, and this can compromise patient care. Second, medicine is a field characterized by lifelong learning, but, without effective use of peer feedback, clinicians are not learning nearly as much as they could from one another. Not only are we underutilizing a valuable resource for improving clinical skills and team dynamics, we are also underutilizing a means for improving clinical safety practices, such as glove use and hand-washing. For example, a study on health care workers published in 2000 demonstrated a significant improvement in compliance with hand washing and glove use policies when a peer feedback program was initiated. The impact was transient, however, suggesting that peer review should persist in the medical setting to achieve sustained improvements in safety and other clinical practices.¹ Third, the field of medicine is currently self-regulated and could be at risk for losing its autonomy. If we fail to be critical with ourselves, third parties may decide to intervene in an effort to limit medical errors and improve efficiency.

Why is it so challenging to give and receive peer criticism? One reason is that, because it happens so infrequently, any critique from peers is perceived as an extraordinary event of great seriousness. A physician may be taken aback, reflecting, "Karen must think I'm really doing badly if she felt the need to actually sit down and discuss my performance with me." Moreover, while feedback from identified superiors is expected and people adjust their performance when the boss is present, no one wants to think that his or her peers are constantly sitting in judgment. That said, if people expected and received more consistent feedback from peers, they could improve their performance and get even better evaluations from their superiors while becoming more confident in their clinical skills. For that to happen, however, peer feedback needs to be delivered in a nonthreatening manner. Businesses address these challenges by implementing semiannual mandatory feedback programs. Some employers are using 360-degree evaluations to ensure that every member of the work force receives evaluations from everyone he or she works with. In addition to evaluating his or her employees, the CEO of a company also receives individual, anonymous evaluations filled out by every member of the staff.

Another reason that peer feedback is resisted is that people are not adequately prepared to give it. Strategies for providing helpful comments can be taught, improving people's ability to critique peers. New York University School of Medicine conducts a workshop to introduce these concepts to first-year students, and, shortly after the workshop concludes, students are asked to evaluate their anatomy dissection groups anonymously. The goals are to teach the skills of giving and receiving effective feedback early on in the medical curriculum and to provide numerous opportunities for medical students to further develop these skills in their preclinical years. If we foster an environment in which peer feedback is a common, well-accepted practice, many of the fears associated with the practice will be assuaged, and students, physicians, and patients will all benefit.

How should we encourage the use of peer critique as a learning tool in the medical setting? First, we should make it an integral and consistent part of professional development, starting in the very first year of medical school. If we learn how to critique one another effectively and constructively early on, we will have the skills and the motivation to give feedback on the wards when optimal patient care is at stake. As we incorporate assessments of professional development into the medical school curriculum, we should include evaluations of how well students give and receive feedback. Our long-term goal should be to make peer review a standard and frequent component of the medical culture so that each encounter becomes a less dramatic event. The more we learn to voice our assessments of our colleagues, the easier it will become for us to be on the receiving end.