Feedback in Clinical Skills Feedback in Clinical Skills Session in Pre-clinical Session in Pre-clinical

YearsYears

Dr. Steve MartinDr. Steve Martin

Island Medical ProgramIsland Medical Program

QuestionQuestion

Can we improve Can we improve

acquisition of basicacquisition of basic

Clinical skills by pre-Clinical skills by pre-

clinical year’sclinical year’s

Undergraduate medicalUndergraduate medical

students by enhancing students by enhancing

tutor feedback skills? tutor feedback skills?

HypothesisHypothesis

Improving the quality of tutor feedback toImproving the quality of tutor feedback to

undergraduate medical students (Years 1-2)undergraduate medical students (Years 1-2)

during clinical skills sessions through just-induring clinical skills sessions through just-in

time faculty development will improvetime faculty development will improve

student performance in patient history and student performance in patient history and

physical examination resulting in improvedphysical examination resulting in improved

patient outcome.patient outcome.

Hypothesis:Hypothesis:

Improved tutor feedback skills

Improved quality of patient encounter and clinical outcome

Enhanced acquisition and mastery of basic clinical skills by pre-clinical undergraduate medical students

Faculty Development Focusing on Providing Feedback

FeedbackFeedback

Information describing students' Information describing students' performance in a given activity. performance in a given activity.

Key step in the acquisition of clinical Key step in the acquisition of clinical skills. skills.

Often omitted or handled improperly Often omitted or handled improperly in a clinical training. in a clinical training.

Literature SearchLiterature Search

Confined to:Confined to: Enhancing basic clinical skills Enhancing basic clinical skills

acquisition and mastery. acquisition and mastery. Feedback in Medical Education.Feedback in Medical Education. Apprenticeship /Mentorship/Modeling Apprenticeship /Mentorship/Modeling

in Medical Education.in Medical Education.

Why look at this issue?Why look at this issue?

““Clinical supervisors often do not fail Clinical supervisors often do not fail students and residents even though students and residents even though they have judged their performance they have judged their performance to be unsatisfactory”to be unsatisfactory” Dudek, Marks & Regehr, Academic Med, Dudek, Marks & Regehr, Academic Med,

20052005

Recent accreditation identified the Recent accreditation identified the need for increasing and improving need for increasing and improving feedback.feedback.

Why?Why?

When effective feedback is provided When effective feedback is provided and focuses on directly observable and focuses on directly observable skills and behaviors, important skills and behaviors, important personal and educational progress personal and educational progress can occur, can occur, KatzKatz

What is feedback?What is feedback?

Information describing students' or Information describing students' or house officers' performance in a house officers' performance in a given activity that is intended to given activity that is intended to guide their future performance in guide their future performance in that same or in a related activity. that same or in a related activity. EndeEnde

Giving FeedbackGiving Feedback

Observations are the currency of Observations are the currency of feedback and without them the feedback and without them the process becomes feedback in name process becomes feedback in name only. The observer must be only. The observer must be committed to the process; moreover, committed to the process; moreover, he or she must have well-formed he or she must have well-formed standards (goals) of clinical standards (goals) of clinical competence. competence.

Vanishing Feedback, Vanishing Feedback, EndeEnde

The teacher may be concerned that The teacher may be concerned that the student will be hurt by negative the student will be hurt by negative feedback feedback

Students may ostensibly want Students may ostensibly want information about their performance information about their performance but only insofar as it confirms their but only insofar as it confirms their self-conceptself-concept

MethodologyMethodology

24 undergraduate second year 24 undergraduate second year medical students in the final stages medical students in the final stages of the clinical skills course. of the clinical skills course.

9 experienced physician tutors.9 experienced physician tutors. 14 standardized patients (SP) were 14 standardized patients (SP) were

utilized to provide 96 encounters for utilized to provide 96 encounters for 24 students.24 students.

FD TeamFD Team

Just in-time Faculty development Just in-time Faculty development sessionsession

FD session on Feedback. FD session on Feedback. – What was done right?What was done right?– What needs improving?What needs improving?– What to do next time?What to do next time?

One-way mirrored observation.One-way mirrored observation. Direct observation.Direct observation. Exit interview.Exit interview.

Bipolar Descriptors of Recommended and Bipolar Descriptors of Recommended and Nonrecommended Feedback Techniques, Nonrecommended Feedback Techniques, Hewson, 1998Hewson, 1998

Intention Technique Examples of Behaviours

Orientation & Climate: Prepare person for the session.

Inform person ahead of time,Select appropriate time & location,Provide relaxed, respectful atmosphere, Explain/negotiate agenda

Let’s make an appointment to review your performance.What are your goals for this rotation?Remember the stated expectations for this procedure.

Elicitation: Ask person for self-assessment. Ask what was done well and what could be improved.Ask how the person felt.Use open-ended questions.

How do you think it went?What was done well?What could be improved?

Diagnosis & Feedback: decide where person needs to improve & how much feedback is appropriate; give reinforcing & corrective feedback.

Offer your response to observation of specific behaviours, approach or style.Give your reason in the context of well-defined shared goals.

When you did/said…I was (pleased, relieved, concerned) because…

Improvement plan: develop specific strategies to real situation.

Invite person’s suggestions. Give your suggestions.Suggest articles, consultations.Teach (discuss, demonstrate, coach)

What could you do differently?This is my suggestion…Where will you get help?Let’s reframe the problem.Let’s talk about this.

Application: Apply strategies to real situation Apply planned improvements to current or future plans

What will you do next time?Show me!

Review: check person understands & agrees with what has been discussed & negotiated.

Person reviews his/hers behaviours needing change.Specify consequences.

What do you do well?What changes will you make?By when?What is you don’t?

Feedback Model, Hewson & Little, 1998

Data CollectionData Collection

Unstructured or informal discussion.Unstructured or informal discussion. Structured ‘exit-interviews’.Structured ‘exit-interviews’. Structured feedback forms.Structured feedback forms.

OutcomeOutcome

The common The common theme of all theme of all sources of sources of feedback was that feedback was that these sessions these sessions where effective in where effective in facilitating change facilitating change and improvement and improvement of skill.of skill.

OutcomeOutcome

Students felt increased confidence in Students felt increased confidence in patient encounters that followed patient encounters that followed each feedback encounter.each feedback encounter.

The standardized patients sensed or The standardized patients sensed or perceived the increased confidence perceived the increased confidence the students portrayed and thus the students portrayed and thus noted improved performance. noted improved performance.

Tutor identified improved skill in data Tutor identified improved skill in data collection and presentation.collection and presentation.

Physician tutorsPhysician tutors

Reported:Reported:– Increased confidence in providing feedback.Increased confidence in providing feedback.– Better understanding of what aspect of the Better understanding of what aspect of the

clinical encounter to focus their attention on to clinical encounter to focus their attention on to best serve the students needs and identify best serve the students needs and identify significant areas of need for improvement. significant areas of need for improvement.

– Improved comfort with the ability to phrase the Improved comfort with the ability to phrase the feedback in a constructive manner.feedback in a constructive manner.

Conclusion/Reflections:Conclusion/Reflections:

Just-in time faculty development Just-in time faculty development

focused on providing feedback infocused on providing feedback in

clinical encounters was effective in clinical encounters was effective in

improving the skill level of the studentimproving the skill level of the student

and tutor.and tutor.

Dissemination OpportunitiesDissemination Opportunities

Results of this research will be used toResults of this research will be used to

change the way the clinical skills curriculumchange the way the clinical skills curriculum

is delivered to undergraduate medicalis delivered to undergraduate medical

students. This will allow the trained tutors tostudents. This will allow the trained tutors to

utilize the skills gained during the FD utilize the skills gained during the FD

session during the system-based clinicalsession during the system-based clinical

skills sessions.skills sessions.

PEARLSPEARLS

Engage the learner in understanding Engage the learner in understanding the relevance and need to receive the relevance and need to receive feedback.feedback.

Engage the teacher in the relevance Engage the teacher in the relevance and need to provide feedbackand need to provide feedback

Thank You