Moving Past the Status Quo: Redefining the Feedback Landscape for Junior Clinician-Educator Career Development

The challenge: navigating career development

Dr C's situation is not unique. Many junior faculty enter medicine with a desire to teach, provide excellent patient care, and produce scholarship. However, they often struggle to balance many competing demands. The next steps for junior clinician-educators, a heterogeneous group, can be opaque, without a one-size-fits-all roadmap for success.^1,2

Thus, wayfinding for clinician-educators is challenging. ³ While frameworks for faculty progression can offer excellent guidance, they mainly provide a rough map ¹ that lacks explicit directions. Holding the map is not enough. Guidance, in the form of mentorship, is also essential.^4,5 A mentor, or often a network of mentors, provides a long-term, developmental relationship and draws on their experience, to provide support, wisdom, and insights beyond specific tasks. ⁵

However, while roadmaps and mentorship are essential, by themselves they are often insufficient. ⁴ Finding a professional niche and navigating often byzantine promotion and tenure requirements, while continuing to develop as a clinician, teacher, and scholar, requires immense growth and learning. In addition to possessing a map and receiving guidance, junior facultys growth requires feedback, and feedback for faculty is often sparse, if not absent. Feedback is ideally task-specific (eg, learner evaluations of teachers), iterative, and derived from a multitude of sources. While feedback has the potential to improve performance, its effectiveness depends upon if and how it is delivered, and if and how it is received. ⁶ Crucially, feedback may or may not be occurring for junior faculty in critical domains.

For the first time for many junior faculty, formal assessment systems are absent. Instead of mandated milestones, there is instead a patchwork of data points in the form of patient satisfaction scores and curriculum vitae bullet points. Even when data for feedback is collected, its organization, delivery, and reception are varied. How junior faculty interact with feedback—and whether it ultimately leads to meaningful behavior change—often depends on informal systems of assessment and feedback within their organizations, highlighting the need for more intentional and structured feedback mechanisms. While preparing for a workshop on faculty development, we conducted a literature review on faculty feedback and discovered a contemporary feedback model, MISCA (Message, Implementation, Student, Context, and Agents), that we believe highlights current deficiencies and opportunities for improvement in how junior faculty receive and incorporate feedback in academic health systems. MISCA integrates five key elements: Message, Implementation, Student, Context, and Agents. ⁶ Conceptualizing junior faculty in the “S” or Student/Learner role, MISCA guides how to improve career development for clinician-educators. We will briefly define each element as it relates to clinician-educator career development and provide practical tips to integrate the model into academic medicine (see Table 1).

OPEN IN VIEWER

Table 1.

Implementation strategies for comprehensive feedback using the MISCA model and mentorship at the programmatic or institutional level.

MISCA MODEL	PRACTICAL TIPS
Message: information faculty receive about their performance	Work with faculty to identify ways to generate feedback on different performance domains (eg, clinical care, scholarship) Leverage EMR capabilities to capture and share individual-level feedback for clinical performance Move beyond student evaluation of teaching—consider peer-shadowing programs and direct observation of teaching
Implementation: function that feedback is intended to achieve and internal processes it triggers	Establish a structured mentorship program that emphasizes feedback Ensure constructive feedback is accompanied by guidance and resources to facilitate faculty growth To supplement feedback sessions, provide feedback summaries highlighting common themes and areas for improvement
Student (Faculty) Characteristics: unique characteristics of individual faculty that impact their reception and agentic use of feedback	Empower faculty to identify goals and share ownership of their professional development Connect feedback to their goals Integrate principles of self-directed learning into new faculty orientation Provide resources and tools for self-reflection (eg, Doing- Planning-Dreaming worksheet) (supplement) Orient faculty to effective lifelong learning strategies (eg, reflection on learning, setting goals, and networking) Provide feedback in multiple formats (eg, collated narrative comments, face-to-face meetings, feedback forms)
Context: general approach to feedback and the way it is presented in the institution (eg, timing, mode of delivery, and feedback climate/culture)	Encourage regular check-ins between mentors and junior faculty throughout the year, not just during formal review cycles Provide templates or guidelines for creating an educator's portfolio (eg, spreadsheet of academic productivity) Coordinate feedback sessions to align with key institutional processes (eg, promotion cycle) Create an online resource center where faculty can access materials, guides, and best practices for effective mentorship Develop mentorship guidelines that outline the roles and responsibilities of both mentors and junior faculty
Agents: sources of feedback	Encourage regular self-reflection through journaling or preparing an educator's portfolio Provide tools or frameworks for structured self-assessment (eg, Doing-Planning-Dreaming worksheet, Clinical Educator Milestones 9 ) Use standardized processes to improve specificity of learner feedback (eg, trainee-led clinical competency committee) 19 Implement 360-degree feedback processes including capturing patient and family feedback Create opportunities for groups of trainees to discuss faculty performance, and develop a shared mental model of feedback

Crafting effective feedback messages

In MISCA, the feedback message is conceptualized as the information exchanged between entities to improve performance.^6,7 This information is the sine qua non of the entire feedback process. ⁶ To facilitate effective feedback for clinician-educators, mentors and supervisors need to consider both the content of the feedback message and the overall goals for which the message is intended, as this is likely to impact receptivity and motivation for implementation. ⁸

One way to approach framing feedback for clinician-educators is to use a systems-based framework that organizes feedback into three levels beginning at the individual (personal goals) and then at the meso- (educational unit; eg, clerkship or residency program) and macro- (institutional) levels. For example, individual-level feedback (eg, learner evaluations with comments about good bedside teaching) could lead to feedback at the meso or residency program-level to encourage the same faculty to work on the program's resident-as-teacher initiative. In this way, feedback can better align individual growth with educational unit and/or institutional priorities. ⁸ The use of a roadmap ¹ or explicit faculty frameworks (eg, ACGME Clinician Educator Milestones), ⁹ can help junior faculty contextualize feedback meaningfully.

Furthermore, as MISCA suggests, sensitivity to individual faculty self-efficacy, specialty context, timing, and resourcing is key for effective feedback. Counter to the classical perception of feedback as unidirectional, effective feedback requires conversations, often with a trusted mentor or coach, that co-create a shared understanding of the gap between current and desired performance. One approach is to answer three key questions (modified from Hattie and Timperley): (1) Where is the faculty member going? (eg, goals, feeding up); (2) How is the faculty member going? (eg, current state, feeding back); and (3) Where to next? (eg, closing the gap, feeding forward). ⁷ These questions are challenging and clinician-educators may need to rely upon multiple mentors for guidance as specific answers will vary depending on which professional role(s) (eg, clinical excellence, teaching) are being considered. Coordination among mentors in a well-integrated network would be ideal but may exceed the practical limits of most institutions. Absent this, clinician-educators will likely experience a series of parallel conversations with mentors providing different vantage points of expertise and may benefit from identifying a senior mentor who can help decode seemingly conflicting guidance.

Nurturing holistic growth through implementation

Implementation, as defined by Panadero and Lipnevich, refers to both the purpose of feedback and the process it triggers in the recipient. ⁶ Beyond task improvement, its core aim is to foster growth, not only facilitate academic advancement. For example, feedback on a teaching presentation may not only suggest content improvements but also advise on enhancing student engagement skills. This broader focus on transferable skill development shows how feedback can be implemented to drive actionable changes and practical improvements beyond that specific teaching encounter. Decoding, analyzing, and applying feedback can be challenging. Effective mentorship involves helping individuals discover their strengths, find their niches, and understand the best next steps for personal and professional growth.

Recipients’ reactions to feedback are crucial. For feedback to be effective, content is important, but not sufficient; the cognitive, emotional, and motivational responses of individuals involved are crucial and mentors play a key role in assisting with feedback processing. For instance, transitions like career advancement may trigger imposter syndrome, ¹⁰ leading individuals to doubt their performance abilities despite evidence of competence. This often results in anxiety and shame due to feelings of inadequacy and fear of being exposed as a fraud. Faculty experiencing imposter syndrome often require extra support. ¹¹ Mentors can provide this by recognizing signs of imposter syndrome, offering resources, and creating a conducive environment for faculty to process feedback constructively rather than succumbing to self-doubt and anxiety. ¹¹

Mentors are pivotal in providing feedback on goals and guiding faculty toward self-monitoring and self-evaluation. For example, a mentor may facilitate a dialogue that helps the junior faculty member set specific, achievable, challenging goals, moving past task-level feedback. Mentors should recommend actions consistent with the faculty's established goals and priorities, focusing on actions under the recipient's control. ¹²

Organizations should actively promote and facilitate mentorship networks, providing resources and fostering a culture that values mentoring and collaboration.^4,13 Practical implementation includes mentorship committees, organizing and overseeing mentorship programs, ensuring accountability, and conducting regular institutional mentorship training. ¹⁴ Regular program evaluation of mentorship programs, extending beyond traditional scholarly metrics, is essential for measuring impact, making improvements, and justifying return on investment. ¹⁴

Contextual dynamics: navigating relationships and culture

In MISCA, context describes how assessment, instructional design, and learning climate interact and affect feedback. Clearly, context differs when applied to faculty development. While timing and logistics of delivery are important, it matters if faculty respect, trust, and have relationships (as applicable) with their sources of feedback. Telio et al, in 2015, introduced the “educational alliance,” which emphasizes the crucial role of both context and relationships in feedback. ¹⁵ The approach promotes a bidirectional exchange between individuals, fostering negotiation and dialogue within an authentic and committed relationship. ¹⁵

There are challenges to forming educational alliances for clinician-educators in academic medical centers. Rather than relationship-based and bidirectional, feedback is often not part of an educational alliance, and rather consists of disembodied inputs (eg, individual clinical metrics, compiled teaching evaluations). We believe that optimizing feedback in this context requires reconnecting these feedback inputs with actual people. Practically, this requires mentors to contextualize and decode feedback for junior faculty. It also means placing an emphasis on developing personal relationships and a cultural shift where mentorship is viewed as an integral part of the leadership mission. All of this requires commitment from leadership to prioritize and support mentorship initiatives that support conditions for educational alliances to develop and thrive. ⁵

Feedback agents with diverse perspectives

The agent domain considers how individuals interact with the various sources of feedback, which may include the individual themself, peers, the teacher, or technology. ⁶ In the case of junior faculty, the role of the “teacher” can be fulfilled by a variety of stakeholders and not just their mentor(s). For instance, medical students or residents a faculty works with can assume the role of a “teacher” when they provide feedback from their unique perspectives.

While feedback is mandated for trainees, we recognize that many faculty members do not receive adequate feedback, or they may only receive informal input from colleagues or mentors.^9,16–18 Trainee-derived feedback (eg, teaching evaluations) may provide some aid to faculty, but only focuses on one domain of performance and often lacks specificity. ¹⁹ To improve feedback specificity, some programs have implemented trainee-led clinical competency committees assessing faculty using a modification of the ACGME's trainee milestones for their specialty, yielding actionable feedback. ¹⁹

Peer assessment is an underutilized source of feedback and near-peer feedback has been shown to be effective in other contexts.^20–23 When combined with other sources like supervisor feedback, it can begin to move the needle towards a 360-degree feedback approach, providing triangulation from different perspectives. For faculty, this may come in the form of peer coaching, especially when there is an opportunity for interaction with the coach, and there is a supportive relationship and focus on individualized goals. ²⁴ Although feasibility barriers such as recruitment and competing demands may limit this approach, we feel this is an opportunity for institutional implementation.

It is important to also cultivate faculty themselves as foundational sources of feedback. Indeed, Panadero and Lipnevich argue that the learner (ie, faculty) should not merely receive feedback passively but actively create their own feedback. ⁶ To do this effectively, most faculty require training and tools to guide this self-reflective process. ²⁵ Rubrics (eg, ACGME's Clinical Educator Milestones) ⁹ can provide points of reference for faculty to get started. Faculty may also benefit from prompting to help them reflect on what they are doing, planning, and dreaming (supplemental figure). With self-reflection exercises such as this worksheet, the role of the mentor would be to help faculty identify and cultivate their interests and passions within the context of the larger organizational mission and available resources (personal communication, Louis Pangaro).

Understanding faculty characteristics

The central focus of MISCA revolves around the feedback recipient themself. Each junior faculty member is unique, and each individual's feedback processing will vary due to individual traits and idiosyncrasies (eg, motivational beliefs, prior knowledge, gender, cultural differences, etc.). What makes each of us unique influences interactions among all the other elements within the feedback model. ⁶ In other words, we all need individualized approaches to navigate career development. With this in mind, let us revisit our case.

Before the meeting, Dr C's Chief reached out with what to expect during their upcoming discussion. Dr C completed a “Doing-Planning-Dreaming” worksheet, which her Chief reviewed in preparation. During their meeting, Dr C and her Chief reviewed her end-of-rotation student evaluations of teaching together, which allowed them to contextualize feedback and identify key themes. While discussing Dr C's self-reflection worksheet, they identified potential mentors in her areas of scholarly interest, and her Chief emailed mutual introductions as the meeting concluded. Dr C left feeling energized.

Harnessing feedback for faculty development

Clinician-educators can know where they want to go (eg, academic progression roadmap) and have guidance (eg, mentorship) to move forward, but without sufficient feedback, their career progression will likely remain suboptimal. Harnessing feedback is challenging, but the MISCA model provides a lens for junior faculty, mentors, and academic medicine leaders to consider how feedback is already occurring at their institutions and where feedback processes could improve. By attending to each element of MISCA, institutional and educational unit leaders can work together with faculty to discover the rewarding paths in their journeys as clinician-educators.