A Donkey’s TailFeedback Webinar 2013

Shannon Waterman, MDSwedish Family Medicine Cherry Hill

Seattle, Washington

Objectives

What is feedback?

Examples of effective feedback

Ask-Tell-Ask (think sandwiches…)

Skills practice and cases

TED: Brené Brown’s “The Power of

Vulnerability”

Pause for pollTeaching

Pause for pollTraining

Feedback Is Not Evaluation

What words of feedback might he need?

What evaluation might he get?Is generic praise helpful?

Pause for pollRealms of feedback

Feedback vs. Evaluation

Feedback Evaluation

Balanced

Looks toward the future

Coaching

Red ink in the margin

One-way

Reviews recent past

All-Star Voting

Final grade

Parallels?

Pause for pollYour experience?

Elements of Effective Feedback

1. Expected, timely and routine

2. Based on first-hand information

3. Descriptive rather than evaluative

4. Focused on issues learner can control

5. Specific and concise

6. Private

7. Reciprocated

Ende J. Feedback in Medical Education. JAMA. 1983

Pause for questions and pollBarriers?

Barriers to feedback

Vulnerability (want to be liked, avoid conflict) Poor observers, unable to “unpack” our observations Limited time Different capabilities of learners at different levels Myth (generational?)

Adult learners do not need feedback. “I never got any feedback, so why should you?”

How good are we? Surgery

86.2% attendings felt feedback given “often/always” after incident vs 12.5% residents

85.7% attendings felt feedback on specifics vs 54.2% of residents

96.6% attendings felt feedback started with positivesvs 54% of residents

69% attendings felt they gave “complete” feedback vs 16.7% of residents

Liberman et al. Surgery residents and attending surgeons have different perceptions of feedback. Medical Teacher. 2005:27(5), 470-72Thanks to Uniformed Services University, Jessica T Servey, Lt Col, USAF, MC. Director, Family Medicine Clerkship

How good are we? Internal Medicine

8% residents “very satisfied” with feedback 80% stated “never” or “infrequently” received corrective

feedback

Family Medicine Inpatient feedback only 14% of comments specifically

targeted

Emergency Medicine Attendings more satisfied with timeliness and content

than residents Attendings rate as constructive more often than

residents

Sostok M, Coberly L, Rowan G. Feedback Process between Faculty and Students. Acad Med. 2002;77(3), 267.

How good are we? MSIII students, Internal Med rotation at Ohio VA 1 hour bedside history & physical observed (58

sets) Feedback given, questionnaire completed

Perception of time spent on feedback similar (26 minutes)

Number of items covered: 3.3 by faculty report and 2.7 by student report

Only 34% agreement in content of the feedback

Sostok M, Coberly L, Rowan G. Feedback Process between Faculty and Students. Acad Med. 2002;77(3), 267.

Abridged history of feedback

The Old Feedback Sandwich The New Feedback Sandwich

Praise / Criticism / Praise Ask / Tell / Ask

Ask - Tell - Ask

Ask learner to assess own performance.

Have you seen a patient like this

before?

What went well?

What could have gone better?

Cases – Why “Ask”?

Reflecting on encounters in medicine can deepen our satisfaction and engagement with what we are doing.

It can help us recognize the profundity of what we do.

Developing your ability to reflect may decrease burnout.

Ask - Tell - Ask Tell what you observed

React to the learner’s observation Feedback on self-assessment

Include both affirmative and corrective elements “I observed….”

Give reasons in the context of well-defined shared goals “You want to become more skilled

with cervical exams...”

Ask - Tell - Ask

Ask about learner’s understanding. “Teach-back.”

Explore strategies for improvement. “What could you do differently?”

Replay relevant part of encounter

“Show me how you might phrase…”

Focus on the behavior you want to see…

General Strategies Reinforce positive behavior – catch

them doing something right“I appreciated how you incorporated the

family into your presentation this morning.”

Redirect negative behaviors“I’d like to give you feedback on your

presentation. When there is a family present on rounds, be sure to start with an introduction of the team.”

Feedback: Be specific Vague: “You seem bored on rounds.”

Specific: “Sometimes you leave the room before we finish discussing a case. I think it is important for all of us to hear about other cases for education and cross-cover.”

Vague: “You seem disorganized.”

Specific: “On work rounds it might be more efficient to see all the patients, then write orders, review x-rays and then talk to consultants.”

Feedback: Be Specific Vague: “Be more careful with the reflex

hammer.”

Specific: “What did you learn from your exam? Here, let me demonstrate how I do the reflex

exam and I think you’ll be able to pick up more subtle differences.

Does that seem like a technique you could use

with your next patient?”

Feedback: Be Descriptive Vague: “You relate well to patients.”

Specific: “How did that go for you?

When you asked who would care for her dog when she is admitted for surgery, I saw her visibly relax. Your caring insight helped change the whole tone of the conversation.

Did you notice that change in her affect? Was that a natural thing for you to do?”

Environment provides feedback

Patient and patient’s family

Peers (student, residents)

Staff and consultants

Own personal perception*

Why learners don’t “hear” feedback? Receiver doesn’t:

Recognize feedback when it is given Understand the message Reflect on the meaning

Giver: Doesn’t make time to give feedback Gives feedback in public setting (shaming,

humiliating) Vague examples

Interplay between giver/receiver:

Heard and taken as personal criticism…personality or style conflict…distrust based on gender/culture

“Take performance to the next level”• Tell them what they’re doing right (they may

have done it on accident!)

• Positive, reinforcing feedback can be followed with restating new goals to reach a new level.

• For any student or resident, the end of one rotation is the start of the next. Help them define their next goals.

Red Flags – Take Action!

Behavior that is unsafe, unethical, unprofessional should be addressed immediately.

Discuss with learner promptly and privately.

Notify attending. “No Surprises” policy. Note learner’s progress and improvement.

Comment on this in evaluation, if appropriate.

Objectives

What is feedback?

Examples of effective feedback

Ask-Tell-Ask (think sandwiches…)

Skills practice and cases

TED: Brené Brown’s “The Power of

Vulnerability”

Feedback is welcomed!

Cases – Resident inpatient service You sit down with the intern for a feedback

session at the end of your inpatient week.

You begin with some of the things she has done well, then turn to the areas she needs to work. Team feedback (and evaluation) suggests she is performing at a solidly average level.

You bring up several patients whose past medical history she had not investigated adequately and comment that she needs to be more succinct in her write-ups.

Cases – Giving student feedback The resident gets angry. “There is never anytime

for me to see the patients.” She considered it great time management and commitment on her part that she would wake patients up at 4am to get a more complete history.

She also feels that you have not helped her or understood that she was taught to “write long notes for the attending.”

Cases – Giving student feedback What went wrong? How could you have made this

a more effective evaluation session?

“ You need to continue working on your efficiency. You improved substantially by keeping a list and learning to prioritize better, but you still need to work on shortening your notes.” Is this good feedback? Is this effective feedback?