giving feedback in the clinical setting 11-3-15.ppthippocrates.ouhsc.edu/comweb/academy/ats/giving...

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GIVING EFFECTIVE FEEDBACK IN THE CLINICAL SETTING

Joseph Gigante, M.D.

Professor Pediatrics

Vanderbilt University School of Medicine

Relevant Disclosure

Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months.

Joseph Gigante

I have no relevant financial relationships or affiliations with commercial interests to disclose.

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OBJECTIVESAt the end of this session participants should be able to:

Describe characteristics of effective feedback and how feedback differs from evaluation

Discuss the guidelines for giving & receiving feedback

Compare and contrast the Feedback Sandwich and the Ask‐Tell‐Ask…Teach models of delivering feedback.

Describe practical ways to mitigate common barriers to effective feedback

Apply the effective feedback guidelines to case vignettes

Receiving Feedback: An Analysis

Consider an experience as a feedback recipient that had a strong impact on you (positive or negative).

How/why did that impact you so strongly?

What do these experiences reveal about what inhibits or enhances effective feedback‐giving?

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• Timely

• Specific

• Targeted to behavior

• Formative

• Based on direct observation

• Limited to 1-2 items

• Necessary and Expected

• “Feedback is designed to influence, reinforce, or change behavior,

concepts or attitudes.” Beverly Wood, MD “Feedback: A Key Feature of Medical Training” Radiology, 2000

What Is Feedback?

• Judgmental

• General

• One time

• Punitive

• **Evaluation

What Isn’t Feedback?

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FEEDBACK VS. EVALUATION

Feedback =Formative Evaluation

Evaluation=Summative evaluation

Purpose Improvement Judgment

Timing Throughout End

Evaluator Preceptor & trainee Preceptor

Standards Incremental steps End goals

Uses Give feedback, identify strengths & weaknesses, develop a plan

Grades

Judge competence

Characteristics of FeedbackFeedback should

– Be undertaken with teacher and trainee working as allies with common goals

– Be expected

– Deal with specific performance, decisions, or actions rather than assumed intentions

– “Feedback is designed to influence, reinforce, or change behavior, concepts or attitudes.”Beverly Wood, MD “Feedback: A Key Feature of Medical Training” Radiology, 2000

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Preparing for Effective Feedback

Establish an effective learning climate

– Clarify expectations the first day

– Communicate and share goals for the learning experience

– Review schedule

– Assign patients, establish call schedule

– Promote self‐regulated learning

– Alert trainees to the use of the “F” word

Types of FeedbackBrief (Informal) Feedback (“Feedback on the Fly”)

– On the spot or soon after

– Observed knowledge, attitude or skill

‐Use after watching an interaction (i.e. Direct Observation in Clinic, ED, Family Centered Rounds)

‐Offer tips on how to improve:“Next time I would try asking the question this way…”“When I examine a baby’s ears, I hold the otoscope this way.”

This feedback is very helpful to learners!!!

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Types of FeedbackFormal Feedback

– Set aside specific time (ex. given just after a clinical presentation)

Major Feedback

– Occurs during scheduled sessions during a rotation (midpoint)

– Serves to provide information to trainee so they can improve before end of rotation

Without Feedback

Good Behavior is not reinforced

trainee will make assumptions

Mistakes GoUncorrected

Silence may indicate approval

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Barriers to Effective Feedback• Lack of knowledge

– Don’t know it is part of the teaching role

– Don’t know elements of effective feedback

• Lack of skills

– Don’t know how to discuss performance honestly and effectively

• Lack of motivation

– Want to avoid the potential negative reaction and resulting discomfort

– Little or no consequence if faculty do not provide feedback

– Relative lack of appreciation of the importance of frequent & effective feedback

Barriers to Effective Feedback• Lack of resources

– Time

– Opportunities for direct observation

• Non‐supportive culture

– Not the norm in medical education

– Not clearly articulated expectation of medical teachers

– An assumption that trainees really know when they are & are not performing well

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• Detects and discusses emotional responses of learners

• Proficient in handling conflict

• Asks what learners desire from teaching session

• Writes down or reviews professional goals

• Works to establish mutual goals, objectives and ground rules

• Lets learners figure it out themselves, even if learner has to struggle

Menachery D, et al. Physician Characteristics Associated with Proficiency in Feedback Skills. J GEN INTERN MED 2006; 21:440-446

Who Is Proficient at Giving Feedback?

• Learner centeredness

• Demonstrates teacher’s respect for learner’s capacity to:

o Identify own goals

o Actively participate in own learning



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“Teachers who are active and interested in eliciting and using feedback for their

own development will be similarly engaged in providing feedback to

learners.”



GUIDELINES FOR GIVING EFFECTIVE FEEDBACK

1. Outline the expectations for the trainee

2. Prepare the trainee to receive feedback

Make it part of the orientation

Make it private

Make it timely

Actually say the word “Feedback”

Gigante J, Dell M, Sharkey A. Getting beyond "good job": How to give effective feedback. Pediatrics. 2011 Feb;127(2):205-7.

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3. ‘STOP’ and give feedback

S=Specific

T=Timely

O=Observed behaviors

P=Plan for action

Gigante J, Dell M, Sharkey A. Getting beyond "good job": How to give effective feedback. Pediatrics. 2011 Feb;127(2):205-7.

Reinforcement

Constructive Comments

Reinforcement

Learner Reflection

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• Modification of feedback sandwich

• Teacher’s comments are preceded by learner’s observation

• Allows for discussions about performance after the event, instead of at the bedside

• Allows for more detailed review than the sandwich

• Encourages learner to reflect on what should be maintained or developed regarding their own performance

Ask-Tell-Ask…Teach

Cantillon J, Sargeant P. Giving Feedback in Clinical Settings. BMJ 2008; 337:1292-1294.

Step 1: The learner is asked what they thought went well in the encounter.

Step 2: The teacher states areas of agreement and further discusses what the learner did well.

Step 3: The learner is asked what they thought went poorly in the encounter.

Step 4: The teacher informs the learner what could have been improved and a plan is developed.

Ask-Tell-Ask…Teach

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ComplimentMakes someone feel good

You are doing a great job

Effective Feedback

Aimed at encouraging good performance

That case presentation gave me detailed, useful information on how to diagnose and treat otitismedia


Criticism

Demeaning or belittling

It’s annoying when you are late.

You are too shy.

You are disorganized.

Your differential diagnosis was inadequate.

Effective Feedback

Aimed at improving performance

You are often late.

I asked you for input, and you did not respond.

You included physical exam findings in your HPI.

Your differential diagnosis did not include TB.

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4. Agree on a plan for improvement

Suggest ways to improve performance

Develop an action plan with the trainee

Elicit suggestions from trainee

Give consequences, if applicable

Gigante J, Dell M, Sharkey A. Getting beyond "good job": How to give effective feedback. Pediatrics. 2011 Feb;127(2):205-7


5. Understanding is confirmed to insure clear communication

Make sure it is understood

One approach is to say to the trainee, “As a result of our meeting tell me what you will do differently.”

Gigante J, Dell M, Sharkey A. Getting beyond "good job": How to give effective feedback. Pediatrics. 2011 Feb;127(2):205-7

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Millennial Generation

• Born between 1982 – 2005

• Highly protected and overscheduled

• Raised by parents who told them they were “special” and “winners”

• Also known as Generation Y

Core Values of Gen Y

Teamwork

Free Expression

Close with Authority

Creativity

Social Networks

Hands‐on Experience

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The Millennial Generation wants learning to be creative, interactive, and fun; and they enjoy

thinking outside the box

Lipkin NA, Perrymore AJ. Y in the Workplace


• Mentoring is important

• More “peer mentorship” than “topdownmentorship”

• Not as independent as their predecessor generations

• Require more structure, guidance, and regular feedback

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Case 1: Organizational SkillsDr. Roberts is completing her rotation in your subspecialty. She is well liked by everyone but seems indecisive and disorganized. She has difficulty prioritizing. As a result, she does not get to see the sickest patients until the end of the day, when it is difficult to organize tests and seek help. She often pages you to ask about little things, though she does not always remember to tell you about more important problems. Lately she seems worried and withdrawn.

Adapted from Steinert. BMJ.2008;336:150-153.

Case 2: Communication Skills

Ward staff have complained to you about Dr. James who

has been working with you for a little less than one week.

Apparently he is slow to answer his pager, ignores

requests to complete discharge summaries, and can be

abrupt with staff and patients. He often makes dismissive

comments about patients and other team members.

However, no one doubts his medical competence.

Adapted from Steinert. BMJ.2008;336:150-153.

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Case 3: Hand Over

Dr. Smith is the intern and Dr. Carter is the supervising resident on the hospital’s night team. Together, they admit a patient with limp from the ED where the work‐up was started by a different resident, Dr. Forrest. After reviewing the case in the morning, you feel key components of the work‐up and management were missed. This is not the first time you have felt this way about an admission to your service.

Characteristics of Effective Feedback

Feedback should:

Be undertaken with teacher and trainee working as allies, with common goals

Be well timed and expected

Be based on first hand data

Deal with specific performance, not generalizations

Offer subjective data, labeled as such

Deal with decisions and actions, rather than assumed intentions or interpretations

Ende, JAMA.1983;250(6):777‐781

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Conclusion

Feedback is necessary

Feedback is valuable

Feedback requires courage, skill, understanding and respect for others.

With practice and planning, it is not as difficult as one might think.

References on FeedbackBing‐You RG, Bertsch B, Thompson JA. Coaching medical students in receiving effective feedback. Teaching and Learning in Medicine. 1998;10(4):228‐231. Ende J. Feedback in clinical medical education. Journal of the American Medical Association. 1983;250(6):777‐781.

Gigante J, Dell M, Sharkey A. Getting beyond "good job": How to give effective feedback. Pediatrics. 2011 Feb;127(2):205‐7.Hewson MG, Little M L. Giving Feedback in medical education: Verification of recommended techniques. J General Internal Medicine. 1998;13(2):111‐116. Kassenbaum DG, Cutler ER. On the culture of student abuse in medical school. Academic Medicine. 1998;73:1149‐1158. Morgan MK, Irby DM. Characteristics of constructive feedback in medical education. Evaluating Clinical Competence in the Health Professions. St. Louis; Missouri: C.V. Mosby;1978 (Appendix 14‐A):185‐186Schurn TR, Yindra KJ. Relationship between systematic feedback to faculty and ratings of clinical teaching. Academic Medicine. 1996;71:110‐1102.

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RECEIVING FEEDBACKRemember feedback is not criticism. It does not mean you are a bad student, resident, or teacher. It is a sign of your teacher’s investment in your learning

Set your own goals and be diligent about assessing your own success at achieving them

If feedback is too general, ask questions to focus on your specific concerns

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CASE 1

One of your senior residents is less efficient than most and has a below average fund of knowledge based on your observations of her at conference. One of the nursing managers calls you one Tuesday morning to tell you that she had received reports from two different nurses the prior evening stating that this resident had been rude and short with the night nurses (e.g., yelling at the night nurse for calling her on a patient with abnormal vital signs).

• How do you approach this resident?

• What exactly do you say to her?

• Other issues to consider?

ROLE PLAYS

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Case 2: Brief, immediate feedback

You are the hospitalist on service and get a call from the intern in the ED about an admission to your team, a 7 week old febrile neonate, with vomiting and diarrhea. The intern tells you the lab‐work is normal & assures you the infant is “tucked in.” Electrolytes, which are drawn in the morning, reveal a Na+=124. When you review the IVF, you note the patient is receiving a hypotonic solution at 2 times the recommended volume.

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