Keep-Start-Stop (Students from Avoiding Constructive Feedback)

By: Kelsie Skaggs, PharmD and Clark Kebodeaux, PharmD, BCACP

“Great job! Keep up the good work!”  

The first time I was instructed to provide feedback in pharmacy school, I’m pretty sure this is how it sounded. Though I naturally provided positive comments, I was challenged to formulate constructive feedback with specific, objective suggestions for my peers to build on strengths and grow in areas of improvement.  At the time, I did not realize how invaluable this skill would be as a pharmacist.  Now, after two years of residency, I can tell you it is critical to successfully provide, acknowledge, and apply constructive feedback.  

Providing feedback to students is consistently recognized as both challenging and essential, as instructors strive to refine performance and encourage setting goals in areas of improvement. Giving feedback can be seen in a similar light as coaching athletes throughout their training.1 This analogy aligns well with the four preceptor roles described by the American Society of Health-System Pharmacists (ASHP):

  • Instructing
  • Modeling 
  • Coaching
  • Facilitating 

In the coaching role, a preceptor effectively uses guidance and feedback to support progression to successful facilitation of activities.  Not only is this an important skill but ASHP accreditation standards for residencies state a resident must be able to apply the four preceptor roles by the end of the resident year, including the skill of providing feedback.  With the ever-increasing percentage of pharmacy students pursuing post-graduate residency training and subsequently obtaining positions with high preceptor loads, it is important to support students in the development and enhancement of feedback skills prior to graduation.

There are choices to make

There are multiple feedback models in the literature to choose from when designing curriculum, such as keep-start-stop, Pendleton’s model of feedback, sandwich method, situation-behavior-impact, and many others. While all feedback models have their strengths, keep-start-stop (KSS) is simple to implement in higher education and produces constructive feedback statements of improved quality.2 KSS asks three simple questions: 

  • What should I keep doing?
  • What should I start doing?
  • What should I stop doing? 

These questions seek to provide guidance on specific behaviors.3 The KSS model may be ideal for students as the verbs serve as clues for providing constructive feedback by focusing on the performance of an individual rather than the individual themself (Figure 1).

Figure 1: Keep-Start-Stop 

Incorporation of a feedback model 

Teaching pharmacy students how to provide effective feedback with any model can be accomplished through near-peer learning, a widely used pedagogical approach.  Near-peer learning is a strategy to develop self-awareness, leadership, and professionalism, and it promotes deeper learning, provides peer support, and cultivates supervision skills.  Providing and receiving constructive feedback parallels near-peer learning, allowing students to gain experience in an environment they find less intimidating than with instructors or preceptors.4

Near-peer learning has been utilized since the start of the new curriculum at the University of Kentucky College of Pharmacy. It is embedded specifically within the Patient-Centered Care Experience (PaCE) sequence, which combines experiential, service, and simulation learning. Students attend a two-hour weekly lab session for the simulation aspect in three modules (institutional, patient care workshop, and ambulatory care).  In the ambulatory care module, there is a series of activities designed to introduce, practice, and implement smoking cessation principles.  One of the activities consists of a patient case in which the first-year pharmacy (PY1) student portrays a patient seeking smoking cessation counseling, the second-year pharmacy (PY2) student conducts the counseling session as a student pharmacist, and the third-year pharmacy (PY3) student practices being a preceptor and provides constructive feedback following the counseling session.  All three classes of students utilize a specific smoking cessation counseling rubric as well as provide feedback (to peer or to self) utilizing the keep-start-stop method (Figure 2).  In this near-peer learning activity, the feedback highly differs between each class, with the PY3 class providing the most constructive, effective feedback that reinforces or corrects the PY2 student’s process.  Feedback for PY1 and PY3 students is assessed for completion by a Teaching Assistant (TA) and effective feedback examples are shared with the class to reinforce effective feedback and balance faculty workload.

Figure 2: Near-Peer Learning 

Opportunities for enhancing feedback 

This structured approach allows students to provide standardized feedback to multiple levels of learners while providing a framework for self-reflection.  When feedback is delivered effectively, students can have increased self-awareness and motivation to identify ways to learn and grow. One PY3 student reported, “This feedback model is simple to follow and remember when reflecting on my own performance.” Instilling this skill early on in training may over time support an overall change in pharmacy student mindset, allowing for increased acceptability of the need for continuous growth and development.5  How are you teaching the skill of providing feedback to pharmacy students at your institutions?


1. Hall A, Miguel A & Weitzel K. Providing feedback to learners in outpatient and ambulatory care practice settings. Currents in Pharmacy Teaching and Learning 2015; 7:348–356. doi: 10.1016/j.cptl.2014.12.007

2. Hoon A, Oliver E, Szpakowska K & Newton P. Use of the ‘Stop, Start, Continue’ method is associated with the production of constructive qualitative feedback by students in higher education. Assessment & Evaluation in Higher Education 2014; Published online.doi: 10.1080/02602938.2014.956282

3. DeLong T. Three Questions for Effective Feedback. Harvard Business Review. 2011.

4. Loewen PS, Legal M, Gamble A, Shah K, Tkachuk S, Zed PJ. Learner: preceptor ratios for practice-based learning across health disciplines: a systematic review. Medical Education 2017; 51:146-157. doi:  10.1111/medu.13144

5. Archer JC. State of the science in health professional education: effective feedback. Med Educ 2010; 44:101–108. doi: 10.1111/j.1365-2923.2009.03546.x


Special thanks to Jeff Cain, EdD, MS of the University of Kentucky College of Pharmacy for his guidance on this article. 

Author Bio(s)

Kelsie Skaggs, PharmD is a PGY2 Ambulatory Care Pharmacy Resident at the University of Kentucky College of Pharmacy and Bluegrass Community Health Center. Her interests include diabetes medication therapy management, student self-awareness and development, and experiential education. In her free time, Kelsie enjoys spending time with her husband, family, friends, and dogs, visiting local coffee shops and restaurants, hiking, and traveling

Clark Kebodeaux, PharmD, BCACP, is a clinical associate professor of pharmacy practice and science at the University of Kentucky College of Pharmacy. He currently practices in an interprofessional ambulatory clinic at Bluegrass Community Health Center—a Federally Qualified Health Center (FQHC) and an accredited Patient Centered Medical Home (PCMH) with a focus on diabetes, substance use disorders and underserved populations. Dr. Kebodeaux currently serves as the Residency Program Director for the PGY1 University of Kentucky Community-Based Residency Program and preceptor for APPE and IPPE student pharmacist rotations.

Pulses is a scholarly blog supported by Currents in Pharmacy Teaching and Learning

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