Garry Sigman, M.D.Associate Professor, PediatricsChairman Student Progress Committee SSOM

FEEDBACK AND REMEDIATION

DEFINITIONS

Feedback: “An informed, non-evaluative, objective appraisal of performance intended to improve skills” Ende, 1983

Remediation

1. (Medicine) affording a remedy; curative

2. (Social Science / Education) denoting or relating to special teaching, teaching methods, or material for backward and slow learners remedial education

Feedback: Micro-remediations- frequent, short encounters with students

Remediation: Methods of correcting problems in students who are performing poorly

MODERN MEDICAL TRAINING

AFTER HAUER, 2010 Feedback

ExperienceFeedback

Experience

Clinical Training

Assessment of Competence Remediation

Advance to next level

THE FEEDBACK SANDWICH

Positive complement

Constructive criticism

Positive complement

PENDLETON’S ‘RULES’

The learner goes first and performs the activity

The learner then says what they thought was done well

The teacher then says what they thought was done well

The learner then says what was not done so well, and could be improved upon

The teacher then says what was not done so well and suggests ways for improvements, with discussion in a helpful and constructive manner

PROPER AND IMPROPER TECHNIQUES FOR PROVIDING

FEEDBACK

Proper Improper

Based on direct observation Based on hearsay

Respectful and supportive Disrespectful, antagonistic

Sensitive Insensitive

Non-judgmental Judgmental

Focus on behavior Focus on personality

Focus on specifics Focus on generalities

Goal-based Not goal-based

Thoughts and feelings of learner sought

Not sought or considered

Suggestions for improvement No suggestions for improvement

After Hewson, Little, 1998

PROBLEMS WITH TRADITIONAL FEEDBACK

Imbedded in hierarchical endeavors of health professionals; educator driven one-way analysis

Reductionist

Formulaic nature is easy to become banal and unbelieved

Does not incorporate psychosocial characteristics of learners

PROBLEMS WITH TRADITIONAL FEEDBACK

Traditional sandwich method- as soon as learner hears praise waits for criticism

Difficult to maintain positive emotional state

“Incompetency attacks”: negative emotional states can dominate interchange and can linger

LEARNER ISSUES WITH FEEDBACK

Self-assessment is not strongly validated; behavior and performance informed by unconscious mind focused on self-preservation

Recipients of negative feedback blame external factors and reject personal responsibility

Learners with high emotional stability, high levels of responsibility, and high sociability more likely to be motivated by feedback

Sargeant, 2006- in intervention group, those who received negative feedback often responded negatively, and behaved as if feedback to be obstructive to change

Poor feedback cause learner to believe that it was useless, burdensome, critical or controlling.

THE NET GENERATION- CHARACTERISTICS

Freedom

Customization

Scrutiny

Integrity

Collaboration

Acceptance

Entertainment

Speed

Innovation

Expression

AGENDA LED- OUTCOMES BASED ANALYSIS ALOBA

Example:

Start with trainee’s agenda

Look at short term outcome

Encourage self-assessment and problem solving

Suggest alternatives

No negative feedback statements; make overall positive comment about performance

REMEDIATION

Implies remedy

Remedy implies diagnosis

Diagnosis is best self-discovered

UTILIZING A MOTIVATIONAL INTERVIEWING APPROACH TO

MACRO-REMEDIATIONFRAMES F- Feedback

(From course, clerkship

Grade and Summation) R- Responsibility A- Advice (from self-

Reflection) M- Menu of options E- Empathy S- Self-efficacy

MODEL OF REMEDIATION PROGRAM

Mentoring

Coaching

Mulitimodal assessment

Diagnosis of deficiencyDevelop individualized plan for learning

Instruction, practice, feedback, reflection

Reassessment

Hauer, et al, 2009

REMEDIATION BASED UPON DEFICITS

Knowledge deficits

Knowledge and skills deficits

Professionalism/interpersonal deficits

Help build knowledge base

Above and practice with feedback

Feedback, instruction, reflection, observation and interaction

REMEDIATION IN MEDICAL EDUCATION

Little evidence for best practices

Small number of studies indicate:

Multi-assessment tools

Individualized instruction

Practice-feedback-reflection-reassment

Bibliography: Feedback and Remediation

•Archer J. State of the science in health professional education: effective feedback. Med Educ 2010:14:101-108.

•Ende J. "Feedback in clinical medical education.” JAMA 1983;250:777-781

•Hauer KE, et al. Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature. Acad Med 2009;1822-1832.

•Hewson M, Little M. Giving feedback in medical education. J Gen Intern Med 1998;13:111-116. •Turner T, Palazzi D, Ward M. The Clinical Educator’s Handbook. Ch. 17. Baylor College of Medicine: 201-212.