R2C2 feedback and coaching resources

R2C2 is an evidence-based reflective model for providing feedback and coaching through an interactive conversation.  It comprises 4 iterative phases:  Relationship, Reaction, Content and Coaching. R2C2 is used extensively in Canada and the US, has been adopted by programs internationally, and has been translated into 4 languages. 

In 2023 it was awarded the Association of Faculties of Medicine of Canada John Ruedy Award for Innovation in Medical Education. 

A guide for R2C2

R2C2 Guide [PDF - 480 KB]

Annotated R2C2 and coaching skills demo: https://www.youtube.com/watch?v=8Zf0IsAVrlw

This video is an annotated demonstration of the R2C2 phases with particular emphasis on the coaching phase and coaching strategies.  It also demonstrates several important features of feedback and coaching; i.e., it incorporates both longitudinal coaching and in-the-moment coaching following a specific incident. It also demonstrates facilitation and coaching approaches to use in a situation which could be challenging, when the learner has not addressed a sensitive issue and needs guidance to do so.

We’re grateful to Sam Lai MD for contributing his acting skills, and Marygrace Zetkulic MD, for her acting and video editing and annotation contributions.   

Dr Sam Lai is Assistant Clinical Professor, Associate Program Director, Internal Medicine Residency Program, Hospitalist and Perioperative Medicine, Department of Medicine, University of California, Irvine Health.   Dr Marygrace Zetkulik is Program Director of Internal Medicine, Assistant Professor of Medicine Hackensack Meridian School of Medicine, Department of Medicine, Hackensack University Medical Center, New Jersey, and a member of the R2C2 research team. 

R2C2 for group/clinic use

R2C2 for residents and other learners, formal progress meetings

Tri-fold: R2C2 for residents’ formal feedback [PDF-581KB]

Below are links to 2 videos demonstrating the R2C2 model in a formal feedback and coaching discussion with a resident.  The first uses more competency-base language while the second is more generic.  A suggestion while watching the videos is to have the Resident Formal tri-fold in hand and try to identify each of the 4 phases and the phrases the supervisor uses, as well as the resident’s responses. 

Video 1 uses competency based language: https://youtu.be/_cSDQYjUEok

Video 2 uses generic language: https://youtu.be/-ljhCWYujks

Sample Action Plan [PDF - 396KB] 

R2C2 for learners ”In the moment”

Tri-fold: R2C2 for learners in the moment feedback [PDF-561KB]

Included are links to various videos demonstrating the R2C2 model in informal “in-the-moment” feedback and coaching discussions:  Feel free to share these with colleagues, students and residents and use in your faculty development sessions. A suggestion while watching them is to refer to the “In-the-moment” tri-fold to identify each of the 4 phases and the phrases the supervisor uses, as well as the resident’s responses. 

Video 1: a brief conversation with a clinical clerk at the beginning of a day to clarify goals and plan the day.  

https://youtu.be/13tDGRoHL1g - Introduction and planning with a clinical clerk (1.5 minutes)

Video 2: the feedback and coaching discussion with the same clerk at the end of that clinic using the 4 phases of the R2C2 model. 

https://youtu.be/MuEnhqjHOlQ - Feedback and coaching the clinical clerk following history taking  (7 minutes)

Video 3:a feedback/coaching discussion with a resident following a family meeting.

https://youtu.be/N0LFPfDk4HY - Planning for, and feedback and coaching with a resident following a family meeting (6 minutes, 22 seconds)

Video 4: a senior learner with a professionalism issue.  This is the full scenario including the coaching.  Videos 5, 6 divide it up for teaching purposes

R2C2 fellow with professionalism issue complete video

Video 5: R2C2 fellow with professionalism issue - first half up to LCP   (i.e, up to the coaching phase; note - LCP is the “learning change plan” developed in the coaching phase)

Video 6:  R2C2 - fellow with professionalism issue - Coaching Plan

Videos 7, 8 provide two feedback scenarios up to the coaching phase.  They are intended for R2C2 practice and teaching sessions to plan the coaching phase:

Video 7: R2C2 resident labeled as lazy - up to formation of the LCP

Video 8:  R2C2 resident who is high achieving up to the LCP coaching plan

R2C2 for nurses

Research and other resources

REFERENCES: Developing and Testing R2C2 by Research Group

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. doi:10.1111/medu.13818 https://pubmed.ncbi.nlm.nih.gov/30779210/

Lockyer J, Armson H, Könings KD, Lee-Krueger RCW, des Ordons AR, Ramani S, Trier J, Zetkulic MG, Sargeant J. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ. 2020 Feb;12(1):27- 35.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012514/

Lockyer J, Lee-Krueger R, Armson H, Hanmore T, Koltz E,  Könings K, Mahalik A, Ramani S, Roze des Ordons A, Trier J, Zetkulic M, Sargeant J,  Application of the R2C2 model to in-the-moment feedback and coaching. Academic Medicine ():10.1097/ACM.0000000000005237, April 14, 2023. | DOI: 10.1097/ACM.0000000000005237

Lockyer J, Lee-Krueger R, Armson H, Hanmore T, Koltz E,  Könings K, Mahalik A, Ramani S, Roze des Ordons A, Trier J, Zetkulic M, Sargeant J,  Application of the R2C2 model to in-the-moment feedback and coaching. Academic Medicine, 2023: 98(9);1062-1068

Roy M, Lockyer J, Touchie C. Family physician quality improvement plans? A realist inquiry into what works, for whom, under what circumstances. J Contin Educ Health Prof. 2023; 01;43(3):155-163. doi: 10.1097/CEH.0000000000000454.

Sargeant J, Lockyer J, Mann K, Holmboe E, Silver I, Armson H, Driessen E, MacLeod T, Yen W, Ross K, Power M. 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. https://pubmed.ncbi.nlm.nih.gov/26200584/

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 https://pubmed.ncbi.nlm.nih.gov/29342008/

REFERENCES: Empirical Research on Using R2C2 by Other Groups

Arabsky S, Castro N, Murray M, Bisca I, Eva KW. The Influence of Relationship-Centered Coaching on Physician Perceptions of Peer Review in the Context of Mandated Regulatory Practices. Acad Med. 2020 Nov;95(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations):S14-S19. doi: 10.1097/ACM.0000000000003642. PMID: 32769452. https://pubmed.ncbi.nlm.nih.gov/32769452/

Awadallah NS, Jones TS, Christian N, Fainstad T, Nyquist J, Schreiber J, Fung CC, Rumack CM, Nehler M, Jaiswal KR. Proactive Coaching in General Surgery Internship: Incorporating Well-being Practices into Resident Professional Life. J Surg Educ. 2023; 80(2):177-184. doi: 10.1016/j.jsurg.2022.09.021.

Curran V, Fleet L, Whitton C. Fostering "Reflection-On-Practice" Through a Multisource Feedback and Peer Coaching Pilot Program [published online ahead of print, 2022 Dec 21]. J Contin Educ Health Prof. 2022;10.1097/CEH.0000000000000483. doi:10.1097/CEH.0000000000000483 https://pubmed.ncbi.nlm.nih.gov/36729010/

Farrell L, Cuncic C, Hartford W, Hatala R, Ajjawi R. Goal co-construction and dialogue in an internal medicine longitudinal coaching programme. Med Educ. 2023;57(3):265-271. doi:10.1111/medu.14942 https://pubmed.ncbi.nlm.nih.gov/36181337/

Fleet, Lisa J. and Curran, Vernon and Whitton, Cindy (2021) NL360+: A Multisource Feedback & Peer-Coaching Pilot Program: Final Evaluation Report. Research Report. Memorial University of Newfoundland, St. John's, Newfoundland and Labrador. (Unpublished) https://research.library.mun.ca/15498/

Graham R, Beuthin R. Exploring the Effectiveness of Multisource Feedback and Coaching with Nurse Practitioners. Nurs Leadersh (Tor Ont). 2018;31(1):50-59. https://www.longwoods.com/content/25472/nursing-leadership/exploring-the-effectiveness-of-multisource-feedback-and-coaching-with-nurse-practitioners

Kind T, Agrawal D. C3PO as a Companion to R2C2 for Feedback. J Grad Med Educ. 2017;9(5):662. doi:10.4300/JGME-D-17-00239.1  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5646932/pdf/i1949-8357-9-5-662.pdf

LaDonna KA, Cowley L, Ananny L, Regehr G, Eva KW. When Feedback is Not Perceived as Feedback: Challenges for Regulatory-Body Mandated Peer Review. Acad Med. 2023 Aug 2. doi: 10.1097/ACM.0000000000005362. Epub ahead of print.

Murthy V, Sethuraman KR, Choudhury S, Shakila R. Application of Practice Oriented-Peer Review for Prosthodontics (PRO-PReP)-A Qualitative Study. Int J Psychiatry Med. 2022;57(2):117-133. doi:10.1177/0091217421990142 https://pubmed.ncbi.nlm.nih.gov/33472469/

Pooley M, Pizzuti C, Daly M. Optimizing Multisource Feedback Implementation for Australasian Physicians. J Contin Educ Health Prof. 2019;39(4):228-235. doi: 10.1097/CEH.0000000000000267. https://pubmed.ncbi.nlm.nih.gov/31567831/

Roy M, Kain N, Touchie C. Exploring Content Relationships Among Components of a Multisource Feedback Program. The Journal of continuing education in the health professions, 42(4), 243–248. https://doi.org/10.1097/CEH.0000000000000398

Roy M, Lockyer J, Touchie C. Family physician quality improvement plans? A realist inquiry into what works, for whom, under what circumstances. J Contin Educ Health Prof. Published online July 06, 2022. doi:10.1097/ceh.0000000000000454

Safavi AH, Papadakos J, Papadakos T, Quartey NK, Lawrie K, Klein E, Storer S, Croke J, Millar BA, Jang R, Bezjak A, Giuliani ME. Feedback Delivery in an Academic Cancer Centre: Reflections From an R2C2-based Microlearning Course. J Cancer Educ. 2021 Jun 24.doi: 10.1007/s13187-021-02028-9. doi:10.1007/s13187-021-02028-9.  https://link.springer.com/content/pdf/10.1007/s13187-021-02028-9.pdf

Sargeant, J., Mann, K., Manos, S., Epstein, I., & Warren, A., Shearer, C., & Boudreau M. (2017). R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ, 9(2), 165-170. doi: 10.4300/JGME-D-16-00398.1.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398131/

Sebok-Syer SS, Shaw JM, Sedran R, Shepherd L, McConnell A, Dukelow AM, Syer MD, Lingard L. Facilitating Residents' Understanding of Electronic Health Record Report Card Data Using Faculty Feedback and Coaching. Acad Med. 2022 Aug 9. doi: 10.1097/ACM.0000000000004900. Epub ahead of print. PMID: 35947480. https://pubmed.ncbi.nlm.nih.gov/3547480

REFERENCES: Other references describing R2C2

Brand PLP, Scheele F. Feedback in de medische opleiding [Feedback in medical education - separate coaching for improvement from summative assessment]. Ned Tijdschr Geneeskd. 2022 Jun 30;166:D6708. Dutch. PMID: 35899738. https://pubmed.ncbi.nlm.nih.gov/35899738/

Ekpenyong A, Zetkulik M, Edgar L, Holmboe E, Reimaging feedback for the milestones era, J Grad Med Educ; 2021: 13 (2S):109-112. https://doi.org/10.4300/JGME-D-20-00840.1  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078073/

Liakos W, Keel T, Pearlman RE, Fornari A. Frameworks for Effective Feedback in Health Professions Education [published online ahead of print, 2022 Jul 19]. Acad Med. 2022;10.1097/ACM.0000000000004884. doi:10.1097/ACM.0000000000004884 https://pubmed.ncbi.nlm.nih.gov/35857394/

Lockyer J, Armson HA, Könings KD, Zetkulic M, Sargeant J, Impact of Personalized Feedback: The Case of Coaching and Learning Plans, In M Henderson, R Ajjawi, D Boud, and E Molloy, The impact of feedback in higher education, Palgrave Macmillan, 2019  https://link.springer.com/chapter/10.1007/978-3-030-25112-3_11

Kind T, Agrawal D. C3PO as a Companion to R2C2 for Feedback. J Grad Med Educ. 2017;9(5):662. doi:10.4300/JGME-D-17-00239.1  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5646932/

Orsini C, Rodrigues V, Tricio J, Rosel M. Common models and approaches for the clinical educator to plan effective feedback encounters. J Educ Eval Health Prof. 2022;19:35. doi:10.3352/jeehp.2022.19.35 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9842479/

Additional resources on feedback and coaching

ACGME, 2023. ACGME Faculty Development Toolkit: Improving Assessment Using Direct Observation

Fu, Belinda MD.. When the Student Gave Me Feedback. Academic Medicine 98(9):p 1082, September 2023. | DOI: 10.1097/ACM.0000000000005295