The Academic Life in Emergency Medicine (ALiEM) Faculty Incubator was hard at work during the pandemic to bring you the fifth volume of the Education Theory Made Practical series. This series strives to make theory accessible to educators by distilling the background and key literature of each theory and grounding them in practical education scenarios.
The Faculty Incubator is a year-long professional development course for medical educators centered around a virtual community of practice (a concept we have all started to appreciate during quarantine). Teams of 2-3 participants from around the world authored primers on education theories and different teams offered a first round of peer review on each post. As in prior years, they will be serialized on the ICE Blog for review and comment. You can learn more here.
They have published three e-book compendiums of this blog series (Volume 1, Volume 2, Volume 3) and you can find the Volume 4 posts here (the e-book is in progress!) As with the previous iterations, final versions of each primer will be complied into a free eBook to be shared with the health professions education community.
Your Mission if you Choose to Accept it:
We would like to invite the ICE Blog community to peer review each post. Your comments will be used to refine each primer prior to publication in the final ebook. No suggestion is too big or small – we want to know what has been missed, misrepresented, or misconstrued. Comments as small as grammatical errors all the way to new scenarios for practical applications or new citations are welcome. (Note: The blog posts themselves will remain unchanged.)
This is the fourth post of Volume 5! You can find the previous posts here: Banking Theory; Constructive Alignment and, IDEO’s Design Thinking Framework.
The R2C2 Feedback Model
Authors: Sean Dyer, MD (@SpyderEM); Geoffrey Comp, DO (@gbcomp)
EDITOR: Michael Gottlieb, MD (@MGottliebMD)
Main Authors or Originators: Joan Sargeant, PhD; Karen Mann, PhD
Part 1: The Hook
Kate is the program director for an emergency medicine residency and is scheduling the upcoming end-of-year reviews. She has received verbal and written feedback that John, a new intern, has been continuing to demonstrate a below-average knowledge base, and has been having a challenging time balancing an appropriate patient load as well as developing appropriate treatment plans on shift.
Early on during the intern year, John struggled to keep up with other members of his class, and Kate had met with him for a mid-year evaluation. She discussed some of the comments she had received about his performance, and he seemed to react negatively toward the feedback. Kate tried to provide encouragement but was concerned that John has not made any changes to help him progress. This frustrates Kate as she took extra time and effort to help John but feels as though she wasn’t able to get through to him.
Before the first feedback session, John felt he was on track for his level of training and was very surprised to receive negative feedback from the faculty. He felt defensive throughout the whole discussion and left the meeting frustrated, thinking that the faculty were unreasonable and were too judgmental.
Kate had hoped that the session would inspire him to make changes but is worried that John will not progress adequately. She would like to have a more constructive end-of-year evaluation session with John to help him meet the potential she sees in him.
Part 2: The Meat
The R2C2 Feedback Model is a structured, four-phase method for providing feedback to learners. The facilitator guides a collaborative discussion through the four steps of building Relationships, exploring Reactions, exploring the Content of the feedback, and Coaching for change, thereby enhancing feedback acceptance and use. [1,2]
In the first phase, the facilitator attempts to build the relationship and establish trust through empathy and establishing credibility of the process. The second phase involves exploring the learner’s reaction to the feedback through open-ended questions and reflective listening with the goal of providing a safe environment. In the third phase, the content of the feedback is examined. The learner is encouraged to clarify any questions about the feedback and identify strengths, weaknesses, and opportunities for improvement. Finally, in the fourth phase, the facilitator provides coaching for performance change through mutual identification of actionable goals as well as specific strategies to attain these objectives. 
Each of these four steps guides the feedback conversation and utilizes specific open-ended questions to promote self-reflection and self-direction by the learner.
Feedback is essential to a learner’s growth and continues to be an important area of study for medical educators. [3, 4] Effective feedback can be used to help a new learner acquire or solidify new concepts. It has been shown to improve technical hands-on skills as well as patient communication, leadership, teamwork, and physician well-being. While the importance of feedback is widely understood, high-quality, evidence-based recommendations for feedback are lacking.
The authors of the R2C2 Feedback Model sought to create an evidence-based and theory-informed model for facilitating performance feedback.The authors sought to address the existing challenges with feedback receptivity and using feedback to inform one’s self-assessment and performance improvement. Using theoretical frameworks and evidence from the literature, the team identified the following three components [2, 6]:
1. Focusing on enhancing individual self-awareness and engaging with the learner through a humanist and person-centred approach;
2. Using an informed self-assessment approach that allows a learner to utilize external feedback to help generate an appraisal of their own performance; and
3. exploring the science of behavior change to enhance the incorporation of feedback.
Through these lenses, the group derived a structured method to “facilitate formal feedback and coaching conversations, enable collaborative discussions between supervisors and residents, and establish a safe environment through a series of open-ended questions that emphasize reflection and continual improvement.”
The authors tested the method and provided both objective and subjective supporting evidence of the benefits of successful implementation of the system. The group performed two studies across multiple sites and programs in graduate medical education, demonstrating that the R2C2 model was effective in engaging residents in a reflective and meaningful goal-oriented interaction..[3,7] The authors also developed and published an online tool kit comprised of templated handouts and video resources for implementation of the program.
The authors surveyed educators and learners after implementation of an R2C2 session and identified three features that were most valuable in successfully providing and accepting feedback. First, the use of open-ended questions was reported to promote a respectful teacher-learner relationship, which was paramount in the success of the session. Second, the discussion was more effective when the content was oriented toward coaching and the learners use of assessment data. Finally, the goal of fostering teacher-learner collaboration assisted in the development of the learner’s goals and determination of areas for growth.
Other examples of where this theory might apply in both the classroom & clinical setting
A modified version of the R2C2 Feedback Model appropriate for shorter interactions has been described . This allows for the teacher to still use the four stages as described above but in a shorter time period without losing the benefits provided by the model. This is a useful variation for teachers to ensure their feedback is given in the moment, instead of waiting until a mid- or end-of-year evaluation. While it was initially developed to guide a formal feedback session, a similar model can be used to help deliver feedback and provide coaching opportunities in real time. For example, an Emergency Medicine attending physician could use the R2C2 model at the end of the learner’s shift, rather than waiting until the end of the rotation.
Annotated Bibliography of Key Papers
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. 
This is the landmark paper from the initial authors that provides the background research, assessment of previous work in the field, and description of the derivation of the R2C2 technique. The article contains an extended description of the methods with specific insight into each of the four components of the theory and examples of how they might be addressed.
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. 
The authors build on their original framework by applying the R2C2 model to a larger population with a variety of learners and teachers. They discuss factors that influenced the quality of the R2C2 sessions including the relationship between the teacher and learner as well as the characteristics of each of the participants. The importance of a Learning Change Plan is emphasized in this article and suggests this might be the most novel and useful part of the theory for the learner as it provides them with a plan to move forward and take action on the feedback they received.
Sargeant J, Mann K, Manos S, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017;9(2):165-170. 
In this paper, the authors describe an approach to integrate the feedback and coaching method into mid- and end-of-year evaluations for residents. Many residencies already have this format of bi-annual or annual feedback already in place; therefore, this is a very practical example of how to integrate the R2C2 into practice with little additional structure. It provides a good framework for supervisors to provide feedback to the learners and incorporate coaching. It was found to be especially helpful in providing feedback and suggestions for improvement to students who were already excelling, as this can be more complicated for supervisors than the student requiring more attention.
Lockyer J, Armson H, Könings KD, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ. 2020;12(1):27-35. 
Previously, the R2C2 model was used primarily for end-of-rotation feedback sessions that encompass multiple types and sources of feedback. This paper discussed how to adapt the R2C2 model to use for individual, shorter encounters, such as at the end of a clinical shift. They discuss variations in approaches to building a relationship with a resident you have worked with multiple times before versus one with whom you have not had much interaction previously.
The R2C2 Feedback Model has several limitations. One of the most commonly cited limitations in the initial articles was the time commitment. It requires a 30-60 minute meeting as well as time for the instructor to learn the technique and time for the learner to review their feedback ahead of time. These issues are partially addressed by the ‘in-the-moment’ modification discussed above. Additionally, in order to achieve meaningful feedback, the learner must be able to self-reflect on their performance and to discuss their reactions to the feedback. For learners who have difficulty with this step, it might limit the quality of feedback and coaching acquired with this model.
Part 3: The Denouement
Kate was determined to lead a constructive feedback session with John and used the R2C2 Feedback Model to structure the discussion.
She started the meeting by setting the stage and building the relationship by explaining the purpose of the feedback session as well as the review process. She asked if he had any other questions, and she was surprised to hear that John was very nervous about the review and didn’t know what he was supposed to learn from the process. John felt much more involved as Kate explained the review process as well as how the feedback was collected.
Kate then asked John to review the on-shift feedback with her. She asked him about his initial reactions as well as if there was anything that was particularly surprising. John was initially visibly hurt and irritated when reading the comments. However, Kate was able to listen and affirm his reactions to the feedback. Ultimately, she discovered he had been wanting to improve some of the weaknesses that were being uncovered but didn’t know how to address them.
By asking if there were any issues with the content of the feedback forms, Kate was able to help John identify that charting on shift was a specific area he wanted to improve. John felt that he was listened to and started to change his opinion of the conversation from a negative, accusatory interpretation to one of encouragement and constructivity.
Finally, Kate was able to help coach John by helping him identify one of his senior residents that he looks up to as a person to discuss charting skills. They also had an excellent discussion about some of the barriers John felt he needed to overcome in order to make the changes in his workflow. Both Kate and John left the meeting feeling encouraged by the discussion and optimistic for a positive change in John’s performance.
Don’t miss the fifth post in the series, coming out Tuesday, August 10, 2021!
PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW
1.Lockyer J, Armson H, Könings KD, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ. 2020;12(1):27-35.
2. 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.
3. 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.
4. Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What Is Known? A Scoping Review. Acad Med. 2017;92(9):1346-1354.
5. Sargeant J, Armson H, Driessen E, et al., Evidence-Informed Facilitated Feedback: The R2C2 Feedback Model. MedEdPORTAL. DOI: 10.15766/mep_2374-8265.10387
6. Armson H, Lockyer JM, Zetkulic M, Könings KD, Sargeant J. Identifying coaching skills to improve feedback use in postgraduate medical education. Med Educ. 2019;53(5):477-493.
7. Sargeant J, Mann K, Manos S, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017;9(2):165-170.
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