Anonymous versus Open Evaluative Feedback in US Academic Medical Institutions: Pros and Cons

Background and Significance

A prototypic US Academic Medical Institution (AMI) is characterized as a “learning organization” that enthusiastically inspires and enables continuous improvement among its myriad stakeholders at all levels, prioritizing knowledge procurement, skill development, and adjusting to changes to augment performance.^1,2 Strategic institutional goals are accomplished by principally nurturing a culture where acquisition of knowledge is embedded in the overarching AMI mission(s) considered vital for success—namely, excellence in the domains of clinical service, teaching, training, mentoring, research, scholarship, innovation, and community engagement.^3,4 Myriad key AMI stakeholders that play a pivotal role include clinicians (physicians, Advance Practice Providers, nursing staff, physical and respiratory therapists and several others), researchers, educators, scholars, students and trainees, administrators, patients, and the public.

Anonymous and open evaluative feedback is critical for AMIs and is designated as an integral element of learning theories (behavioral, cognitive, and social constructivist orientations) for performance improvement in the above-mentioned principal domains.^5–7 Research studies in the literature support that targeted and specific feedback augments learning as demonstrated by improvement in skills in the educational and clinical settings.^5,8,9 A spectrum of evaluative tools is utilized by AMIs to monitor performance and progress in the spheres commensurate with their mission, vision, values and strategic goals. However, there is a paucity of data as to the optimal methodologies that would provide insights leading to identification of barriers, challenges, and suboptimal performance to productive problem-solving in the desired process of continuous learning and improvement.

Anonymity is the ability to communicate and receive information without disclosing one’s identity. This is crucial to safeguarding unpopular opinions and preventing biased retaliation. The right to remain anonymous is a fundamental element of free speech under the First Amendment of the US Constitution,¹⁰ that provides protections from the autocracy of the majority as well as from those in positions of power who might oppress dissenters. There is extrapolation of this concept to the evaluative processes in organizations including US AMIs.

Although anonymity protects privacy, it can also present challenges to holding people accountable and culpable for their beliefs and actions. While controversy and debate will continue,^11–17 this literature-based descriptive treatise explores the subtleties, benefits, and disadvantages of anonymous versus non-anonymous (“open”) feedback in the context of augmenting the overall performance among principal stakeholders in AMIs. This exposition further expounds on the critical and influential role of the organizational cultural milieu and its foundational core embedded in trust and professionalism on evaluative processes in AMIs.^18–20

Anonymous versus Non-Anonymous (Open) Feedback

Clinical Service

In the domains of clinical patient care, anonymous surveys are frequently utilized to monitor trends in patient satisfaction and processes in the delivery of healthcare as articulated by the endorsement in six dimensions encapsulated by the Institute of Medicine (safe, efficient, effective, patient-centered, timely, equitable)²¹ in ambulatory and inpatient service settings. Follow-up of such “snapshots” of data transformed into trends at intervals of varying frequency with composite scoring systems helps delineate areas of relative weaknesses and strengths toward desired improvements in the AMI. Collated data on organizational performance ratings and rankings in specific specialties are published periodically by monitoring bodies such as Vizient, Healthgrades, Leapfrog, Doximity, US News and Health Report, and others in the public domain.²² Although criteria and domain specifics for such rankings may differ among these professional bodies, they are useful in gauging relative performance pertaining to an AMI’s reputation, for third-party payers, and for patients and the public.

Faculty Trainee, and Staff Wellness

Other domains where anonymous surveys are frequently utilized are in the realms of faculty, trainee, and staff wellness and satisfaction (eg, Wellbeing Index) to periodically gauge “burnout”, rates of retention and attrition, and the underlying reasons for dissatisfaction, identifying areas of relative strengths and those that require attention and improvement.^23,24

360-Degree Evaluations

With the rapidly changing terrain of US healthcare and corporatization of AMIs, the use of anonymous 360-degree evaluations that has revolutionized individual performance management continues to grow for middle managers, academic, and administrative leadership.^25,26 When used with caution and thoughtfulness, the appraisal tool along with feedback processes from peers, supervisors, and direct reports with a self-appraisal provides meaningful information for both the organization and those evaluated.²⁵ With this tool, performance management is ranked in important facets such as Planning, Monitoring, Developing, Appraising, and Rewarding by a variety of rating sources to enhance the validity of the ratings against a self-rating. However, others suggest that the 360-degree evaluative process perpetuates bureaucracy, accentuates political tensions within an organization, and expends inordinate amounts of time and effort.²⁶

Education and Training

Debate and controversy exist in the evaluative processes in the sphere of education and training in US AMIs. Literature supports the notion that feedback is particularly important in the medical trainee environment to circumvent the insufficiency of self-assessment when compared to observed measures of core competencies with incongruence between self-evaluation and feedback from others.¹⁶ In fact, such evaluations in six core competencies (Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, System-based Practice) are obligatory for all trainees in the Graduate Medical Education (GME) programs as mandated by the Accreditation Council Graduate Medical Education (ACGME) in US AMIs.²⁷ Conversely, trainees also evaluate programs as well as specific clinician-educators in their supervisory roles. The majority of feedback is provided by undergraduate medical and graduate students and postgraduate trainees (residents, and post-doctoral fellows) to clinician-educators for the quality of their classroom or bedside teaching activities as well as addressing special issues of trainee mistreatment and harassment.^5,28–30 Typically, such assessments use instruments that have a rating scale in conjunction with some qualitative comments and evaluations presented to physician-educators at the end of a distinct clinical rotation or educational activity and annual evaluations presented as an aggregate in anonymous fashion.⁵ These evaluations are frequently utilized to provide clinician-educators with “formative information” toward educator and programmatic improvement, faculty promotion and tenure, or sustained employment toward subserving the AMI’s missions.⁵ Additionally, non-anonymous feedback is utilized by some training programs whereby the feedback recipient is aware of the identity of the provider of such evaluation(s).

There is paucity of evidence-based research focusing on the definitive superiority of one over the other—anonymous versus open feedback. Few AMIs utilize a combination of both methodologies. As mentioned previously, many of these methodologies have been extrapolated from behavioral, cognitive, and social learning theories.^5–7 The advantages of anonymous evaluations (Figure 1) include:^31–34 1) utility of greater candor and honesty; 2) promoting unfiltered communication; 3) higher participations rates by evaluators; 4) ensuring confidentiality; 5) alleviating fear of retaliation by guaranteeing the privacy and well-being of evaluators; 6) being effective in formative feedback;⁵ 7) usefulness in situations where there is a power differential or in hierarchical constructs eg, (educator–trainee relationship) by lessening the psychological pressures on the evaluator; and 8) potential qualitative or quantified (Rating Scale) metrics. The disadvantages of anonymous evaluations (Figure 2) include:^31–34 1) being utilized effectively only with a relatively substantial number of evaluators in order to be truly anonymous; 2) being time-consuming for collating cumulative data; 3) hindering the ability for a meaningful conversation on account of one-way communication; 4) being prone to generating unproductive comments with limited opportunity for clarification or follow-up questions; 5) potential to be exploited as a form of harassment (“tyranny of anonymity”) by utilizing offensive and disruptive communication—eg, a survey from a study of anonymous online comments demonstrated that 53% of anonymous comments lacked civility, compared to 29% of ascribed comments;³⁴ 6) augmenting a culture of distrust and paranoia by infusing doubt as to who to believe or not believe; 7) possibly creating delusions of grandeur if the feedback is positive for those being evaluated; 8) having the potential for negative impact in the absence of a dialogic communication; 8) lacking accountability and clarity; 9) being prone to dismissive rationalization; and 10) having the possibility of resulting in generic or vague feedback.

Figure 1 Advantages of Anonymous Feedback.

Figure 2 Disadvantages of Anonymous Feedback.

Advantages of non-anonymous evaluations (Figure 3) include the following:^31–34 1) having the opportunity for unguarded dialogic communication paving the way for understanding divergent perspectives; 2) enhancing and nurturing organizational trust; 3) strengthening professional and personal relationships; and 4) facilitating ongoing mentoring, coaching, and development.

Figure 3 Advantages of Open Feedback.

The disadvantages of non-anonymous feedback (Figure 4) can be enumerated as follows:^31–34 1) having a potential for confrontation; 2) moderating negative feedback with good intentions of being constructive and not hurtful; and 3) risk of strain to relationships if not delivered with empathy and sensitivity, which requires an open and supportive culture where individuals feel safe to express their thoughts without fear of negative consequences such as subtle or overt retaliation.

Figure 4 Disadvantages of Open Feedback.

Influence of AMIs Culture of Professionalism and Trust

Open or non-anonymous feedback and evaluation requires a foundational substrate that supports an institutional culture of trust among key stakeholders.^18,19 Institutional ethos is buoyed by its core values of integrity, transparency, fairness, effective and timely communication, operating on the principles of meritocracy, tackling interdependent processes for shared responsibility for decision-making, collaborative goal setting, commitment to developing others, and zero tolerance for retaliation. All these key elements must be reinforced by a vibrant AMI’s administrative leadership. Additionally, a culture of professionalism²⁰ augments the intent of open feedback system(s) to include respect for all, humility and selflessness, culpability and confidentiality, a sense of duty and honor, role modeling, collegiality, teamwork, mentoring, coaching, and a commitment to lifelong learning. These attributes are essential elements applicable to stakeholders involved in all domains of academic medicine. Anonymous feedback could still create paranoia and nurture distrust especially in the individual educator-learner paradigm, due to the power differential in the professional relationship. However, there is a need for corroboration with definitive data and evidence. Trust and professionalism^18–20 allow for dialogic communication and effective feedback among parties that serves as a feedback loop toward engendering trust among all stakeholders - an iterative process that takes considerable time, effort, and firm commitment from institutional leadership for an AMI to be characterized as a “learning organization”.^1,2

Caveats and Discussion

Evaluative processes focused on individual, or system performance are critical for AMIs, which represent complex matrix organizations with a multitude of stakeholders (patients, clinical providers, laboratory and clinical researchers, educators, students, trainees, administrative staff, academic community, and the public). Such evaluations are critical for continuous improvement in institutional and individual performance commensurate with the mission, vision, values and strategic goals of the AMI.⁵ There is a paucity of data-driven and evidence-based literature on the superiority of the type of evaluative methodologies as it pertains to anonymous versus open feedback best serving the individual and institutional needs. There are pros and cons to both approaches. This exposition posits that the effectiveness and type of such evaluations depends on the scenario, parties involved, the institutional culture of trust and professionalism, and desired actionable data that is garnered through such an evaluative process. Credible theoretical considerations support the idea that advantages of open feedback via face-to-face dialogic communication far outweigh its disadvantages compared to anonymous evaluations.^5,35

For system and process improvement in the domains of patient care and student and faculty wellbeing and satisfaction, anonymous surveys (qualitative and quantitative) are desirable that involve a large sample size. While response rates are frequently subpar, such isolated snapshots in time are more meaningful if quantifiable data is then presented as trends at pre-determined periodic intervals or following implementation of changes in a focused domain. In the sphere of trainee mistreatment and harassment, anonymous evaluations can play a significant role in bringing issues to the fore because of the reluctance of victims to have an open dialogue with the perpetrator frequently because of the power differential.^27,28 Of note, in one study, there was a high prevalence (63.4%) of reported mistreatment in a meta-analysis of a large cohort of 11,000 medical students with the preponderance being gender discrimination complaints and 33% of residents reporting sexual harassment.²⁹ Such unprofessional behaviors when encountered need to be monitored and addressed expeditiously at the institutional level.

The role of Human Resources is important in designing, implementing, and completing performance appraisals in a timely fashion with clarity and transparency while maintaining confidentiality by acting as a mediator between functional heads or reviewing authorities and all employees in an AMI.³⁶ The legal ramifications of an evaluative process cannot be overlooked. While performance reviews and evaluations are not mandatory according to the US Department of Labor and The Fair Labor Standards Act of 1938, most US AMIs conduct regular performance appraisals. Of note, performance evaluations in the US are subject to a variety of federal (eg, Title VII of the Civil Rights Act of 1964, Americans with Disabilities Act, The Age Discrimination in Employment Act) and state (eg, California’s Fair Employment and Housing Act, Illinois Human Rights Act) laws that protect the rights of employees and prohibit discrimination based on age, race, religion, gender, sexual orientation, and disability in the workplace.³⁶ Similar performance review laws exist in other countries (Russia, China, Germany, UK, France, Spain, Canada, Australia).³⁶ It is critical for evaluators to comprehend the legal requirements for employee evaluations, remaining focused on objective criteria with rigorous documentation, and by conducting regular compliance audits.

As stated previously, 360-degree evaluations (“panoramic view” or “sphere”) are frequently utilized as useful tools for anonymous feedback from peers for middle managers and leadership in US AMIs. This is generally done as a process of self-improvement for those being evaluated by aligning performance measures congruent with organizational goals as well as selecting and training participants being prepared and positioned for promotions and leadership roles.^25,26 Research studies have demonstrated that such an assessment with multiple rating sources provides more accurate, reliable, and credible information with low correlations between self-ratings (consistently higher) and all other sources of ratings.²⁵ The nature of the peer-review evaluation poses some paradoxes in terms of its validity, apprehension over the possibility of diminution in compensation for a negative review, and its application to group performance.²⁶ Furthermore, misapplication of the process, can lead to disagreements, and anxiety that may result in increased rates of employee attrition—eg, a discrepancy between self- and supervisor ratings leading to defensive posturing and alienation by the employee being evaluated. Use of multiple raters in the peer dimension of the 360-degree assessment programs tends to average out the possible biases of any one member of the group of raters. The need for anonymity is essential as subordinates may refuse to participate or may provide gratuitous, dishonest feedback, if there is fear of reprisal from supervisors.^25,26

Despite the creed that anonymous evaluations represent the “Holy Grail” of insurance against bias, explicit and implicit,¹² based on literature-based evidence this treatise posits that for educator-learner feedback, an open exchange allows for effective dialogic communication between the most informed participants and bolsters the student–teacher relationship by supporting learning, enhancing accountability, and allowing for appropriate behavior modifications.³⁵ In previous published reports, open evaluations have yielded more robust and higher-caliber comments in the written narratives from trainees despite some discomfort over the format,¹⁴ and anonymity did not significantly impact faculty evaluations of trainees.¹⁶ In another study utilizing retrospective analysis, faculty evaluations completed anonymously by trainees scored significantly lower than those for which trainees were known.¹⁵ Of note, however, other published studies show that anonymous evaluations for faculty are a more accurate reflection of teaching performance with trainees articulating barriers for optimal evaluation by students that include fear of fracturing the working relationship, and trepidation over encountering the same evaluating faculty member in the future.¹¹ Most importantly, the trainee-educator (“mentor-mentee”) liaison is built on mutual trust as a core value and overriding principle toward enhancing the intent of the symbiotic relationship that fulfills the academic mission(s) of an AMI.^5,18 Lastly, it has been posited that by developing a more holistic evidence-based comprehensive evaluation system for student and trainees via input from “focus groups, peer reviews of teaching, self-awareness and self-reflection”, AMIs will enhance the development of educators in fulfilling their educational and training mission(s) effectively.³⁷

Conclusions and Future Directions

Evaluative processes are critical for an AMI in fulfilling its key missions in a voyage of continuous learning and improvement aligned with organizational mission, vision, values, and strategic goals.^3,4 Most AMIs utilize a combination of anonymous and open evaluative methodologies to enhance systems and processes and to provide determinative data for sustained enhancement in focused domains. Theoretical considerations support the notion that the advantages of open feedback far outweigh anonymous evaluative processes by fostering an organizational culture of trust and open dialogic communication. However, these suppositions need confirmatory evidence from further research that is mission specific. Until such studies are forthcoming, most AMIs will continue to utilize a hybrid methodology with biases and assumptions for evaluative feedback focused on their critical missions.