Say the hard thing well.
Feedback models that work (ask-tell-ask, R2C2), when to involve the program director, SPIKES and NURSE for bad news, REMAP and the Serious Illness Conversation Guide for goals of care, and what to document.
Reviewed October 2026 · verify against current guidelines
Feedback is your job now.
Your evaluation counts
ACGME Internal Medicine requirements call for frequent feedback on every rotation and for evaluations from multiple evaluators, including peers (5.1, 5.1.b.1). As a senior, you see your interns more than anyone else does. Ende's rule from 1983 still holds: feedback is information about observed behavior, meant to guide the next attempt. It is not a judgment of the person.
Feedback that lands
- Set it up on day one: “I'll give you feedback every few days. Tell me if you want more.”
- Make it timely. Same day beats end of rotation.
- Make it specific. Name the action and its effect.
- Make it about behavior, not traits. Say “your plan skipped the potassium,” not “you're careless.”
- Give corrections in private, one or two at a time.
Use a model, not a sandwich.
Two models worth knowing
| Ask-Tell-Ask | Ask how they think it went. Tell them one or two specific observations: what to keep, what to change. Ask what they will do differently, or check that they understood. This model was adapted from patient-communication training (French 2015). |
|---|---|
| R2C2 | For midpoint or end-of-rotation talks. Relationship: build rapport and show you're on their side. Reactions: ask how the feedback lands. Content: clarify what the data mean. Coaching: agree on a specific change plan (Sargeant 2015). It was studied in five residency programs, including internal medicine (Sargeant 2018). |
Why not the sandwich
Praise, critique, praise feels kind. In two studies of written peer feedback among third-year medical students (N=20 and N=350), though, recipients believed sandwiched feedback helped them while their performance did not change (Parkes 2013). The critique gets lost in the bread. Keep praise and correction both specific, and label them clearly.
Midpoint script
| Ask | “How do you think the first two weeks have gone? What do you want to work on?” |
|---|---|
| Tell | “Your presentations are tight. Keep that. One thing to change: on unstable patients, start the first orders and call me at the same time. Don't finish the workup before I know.” |
| Ask | “What would make that easier? What will you do tomorrow night?” |
When an intern is struggling.
Name the deficit
In one remediation program's referrals, the most common deficits were medical knowledge, clinical reasoning and professionalism. Most learners had more than one. Remediation succeeded for 90%, and poor professionalism was the only predictor of probation (Guerrasio 2014). Your job is to notice early, describe it specifically, and hand it to the people who own remediation.
Handle it or escalate
| Handle on the team | A single lapse, a skill gap that improves with feedback, an organization problem. |
|---|---|
| Tell your attending | The same problem after clear feedback, or any near-miss tied to it. |
| Involve the PD or chief | A pattern across days, professionalism concerns, or a concern for patient safety. |
| Act now | Possible impairment on shift, or signs of burnout, depression, substance use or suicidal thoughts. Remove them from patient care if needed and call your attending and the PD or designee directly. If there is any acute risk, don't leave them alone. Use the program's 24/7 urgent mental-health line, 988, or the ED (ACGME 6.13.e). |
What the requirements say
- The PD, with input from the Clinical Competency Committee, develops plans for residents who are not progressing, following institutional policy and due process (5.1.e). Remediation is their job, not yours.
- Programs must teach residents to recognize burnout, depression, substance use and suicidal ideation in colleagues. Residents must know whom to tell besides the PD (6.13.d).
- Programs must provide confidential mental health care, with urgent access 24/7 (6.13.e).
Deliver bad news with SPIKES.
Huddle first
Before any family meeting, meet with the nurse and the consultants for five minutes. Agree on the medical facts, the message, and who leads. If needed, book a professional medical interpreter (not family). Mixed messages at the bedside undo the whole meeting.
SPIKES (Baile 2000)
| Setting | Private room, seated, phone handed off, tissues within reach, the right people present. |
|---|---|
| Perception | “What have the doctors told you so far?” Find out what they already know. |
| Invitation | “How much detail would you like?” Some want numbers; some want the headline. |
| Knowledge | Give a warning first: “I'm afraid I have bad news.” Then share in small pieces, in plain words. Pause. |
| Emotions | Respond to the emotion before adding more facts. Use NURSE. |
| Strategy / summary | Once they're ready, lay out the next steps. Check what they understood. |
NURSE: respond to emotion (VitalTalk)
| Name | “It sounds like you're frustrated.” |
|---|---|
| Understand | “This helps me understand what you are thinking.” |
| Respect | “I can see you've really been trying to follow our instructions.” |
| Support | “I'll do my best to make sure you have what you need.” |
| Explore | “Could you say more about what you mean?” |
Map goals, then recommend.
REMAP for goals of care (Childers 2017; VitalTalk)
| Reframe | Give a headline that shows things have changed: “We're in a different place.” |
|---|---|
| Expect emotion | Pause and respond with empathy. Use NURSE. |
| Map | “Given this, what's most important to you? What worries you?” |
| Align | Reflect their values back: “It sounds like being at home and comfortable matters most.” |
| Propose a plan | With permission, recommend care that fits those values: “Here's what I think we can do to help with that.” |
Serious illness conversation basics
Ariadne Labs' Serious Illness Conversation Guide follows five steps: set up the conversation, assess understanding and information preferences, share prognosis, explore key topics, then close and document. Bernacki and Block's review lists the core topics: prognosis, decision-making preferences, fears and goals, views on trade-offs and impaired function, and family involvement. In a cluster-randomized trial in outpatient oncology, the program did not change its co-primary end-of-life outcomes, but it reduced moderate-to-severe anxiety and depression at 14 weeks (Bernacki 2019).
Write it down.
Goals-of-care note
- Who was there: patient, surrogate, family, interpreter, team members.
- What was shared, including prognosis in the words you used.
- What matters to the patient: goals, fears, trade-offs they would or would not accept.
- Decisions: code status, limits on treatment, time-limited trials and how you'll judge them.
- Follow-up: who meets again, and when. Update code status orders the same day.
Documenting concerns about an intern
- Write observed behavior with dates, not adjectives.
- Note the feedback you gave and how they responded.
- Put it in the formal evaluation. The CCC can only act on what is written.
- Raise safety concerns in real time, not only in the evaluation.
Educational reference only — not medical or legal advice. Verify against local policy and your program's evaluation procedures.
Sources
Verify against current guidelines and local protocol before acting.
- Ende J. Feedback in clinical medical education. JAMA 1983;250(6):777-781.
- French JC, Colbert CY, Pien LC, Dannefer EF, Taylor CA. Targeted feedback in the milestones era: utilization of the ask-tell-ask feedback model to promote reflection and self-assessment. J Surg Educ 2015;72(6):e274-e279. doi:10.1016/j.jsurg.2015.05.016.
- Sargeant J, Lockyer J, Mann K, et al. Facilitated reflective performance feedback: developing an evidence- and theory-based model that builds relationship, explores reactions and content, and coaches for performance change (R2C2). Acad Med 2015;90(12):1698-1706. doi:10.1097/ACM.0000000000000809.
- Sargeant J, Lockyer JM, Mann K, et al. The R2C2 model in residency education: how does it foster coaching and promote feedback use? Acad Med 2018;93(7):1055-1063. doi:10.1097/ACM.0000000000002131.
- Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract 2013;18(3):397-407. doi:10.1007/s10459-012-9377-9.
- Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012. Acad Med 2014;89(2):352-358. doi:10.1097/ACM.0000000000000122.
- ACGME Program Requirements for Graduate Medical Education in Internal Medicine including FAQs, effective July 1, 2026: requirements 5.1, 5.1.b.1, 5.1.e, 5.3, 6.13.d and 6.13.e. acgme.org.
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES — a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311. doi:10.1634/theoncologist.5-4-302.
- Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: a framework for goals of care conversations. J Oncol Pract 2017;13(10):e844-e850. doi:10.1200/JOP.2016.018796.
- VitalTalk. Transitions/goals of care (REMAP) and Responding to emotion: NURSE statements. vitaltalk.org.
- Ariadne Labs. Serious Illness Conversation Guide (revised). ariadnelabs.org.
- Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med 2014;174(12):1994-2003. doi:10.1001/jamainternmed.2014.5271.
- Bernacki R, Paladino J, Neville BA, et al. Effect of the Serious Illness Care Program in outpatient oncology: a cluster randomized clinical trial. JAMA Intern Med 2019;179(6):751-759. doi:10.1001/jamainternmed.2019.0077.
- Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356(5):469-478. doi:10.1056/NEJMoa063446.