Using the New Feedback Sandwich to Provide Effective Feedback

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Using the New Feedback Sandwich to Provide
Effective Feedback
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• Faculty Development Workshop
• Lyuba Konopasek, MD
• John Encandela, PhD
• Gingi Pica, MPH

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• This presentation was developed by Lyuba
  Konopasek, M.D., and the Core Education Committee
  of New York Presbyterian Hospital (NYPH) for use
  as part of a Resident as Teacher curriculum at
  NYPH, Weill Medical College of Cornell
  University, and Columbia University Medical
  Center.
• Acknowledgements
• John Encandela, PhD
• Mark Graham, PhD
• Gingi Pica, MPH

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• Weill Medical College of Cornell University
  designates this educational activity for a
  maximum of 2 AMA PRA Category 1 Credit(s) .
  Physicians should only claim credit commensurate
  with the extent of their participation in the
  activity.

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Objectives
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• Describe rationale for giving feedback in medical
  education
• Describe common barriers to giving feedback
• Identify types of feedback
• Define characteristics of effective feedback
• Observe and practice giving feedback
• Develop an action plan for improving feedback in
  your own practice

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RATIONALE
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Rationale for Giving Feedback in Medical Education
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• Without feedback, mistakes go uncorrected,
  good performance is not reinforced, and clinical
  competence is achieved empirically or, not at
  all.

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781.
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More Rationale
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• High stakes outcomes
• It is our responsibility
• It will help learners improve their performance
• Can enhance the learner teacher relationships

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DEFINITIONS
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• I am thinking of a number between 1 and 100.

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How Do They Differ?
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• Minimal Feedback/Reinforcement
• Evaluation
• Feedback

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Reinforcement/Minimal Feedback

• Statement expressing positive (or negative)
  reaction to a behavior which aims to increase (or
  decrease) the likelihood of that behavior
  happening again
• That was a great presentation
• You need to work on your presentation skills
• Often mistaken for feedback
• Timing is similar - immediate

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Evaluation

• Qualitative judgment which ranks a learners
  performance in comparison to other learners
• 3.7 for professionalism competence
• Often the only measure of performance visible to
  the learner
• Usually given after the performance is over

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Feedback

• (Reinforcement or correction) Explanation
• Keeps you on course to meet goals
• Allows you to adjust your course to meet goals
• Given immediately after the performance or at
  some time soon after, when the learner still has
  time to demonstrate improvement

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BARRIERS
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It is not a part of our culture
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What feedback? No one ever gives me feedback.
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as it is part of other training cultures
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Barriers
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• It is uncomfortable
• Avoid confrontation
• Learner will not be receptive
• No one ever gave me feedback
• Not quite sure how to do it
• I hated getting feedback

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More Barriers
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• Im not sure of the goals or the expected
  behavior
• Not sure that the observed behavior is really a
  problem
• Need to see it twice
• Its not my job
• Its not that important
• Theres not enough time

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TYPES OF FEEDBACK
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Three types of feedback in medical education
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• Brief feedback - 2-5 minutes
• On a clinical skill
• Formal feedback - 5-15 minutes
• On a presentation, involves a dialogue
• Major feedback - 15-30 minutes
• Scheduled mid-point through a learning experience

Branch J, Paranjape A. Feedback and Reflection
Teaching Methods for Clinical Settings. Academic
Medicine. 2002771185-1188.
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ESSENTIAL COMPONENTS
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What are the Essential Components of Feedback?
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• What was done well
• What could be done better
• What could be done to improve next time

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Characteristics of Effective Feedback
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• Well timed and expected
• Based on first hand data
• Regulated in quantity
• Phrased in descriptive language, based on
  specific remediable behaviors
• Should be undertaken with teacher and learner
  working as allies, with common goals

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781.
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The Old Feedback Sandwich
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Praise Criticism Praise Is it more
palatable?
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The New Feedback Sandwich
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Ask Tell Ask
Adaptation of The New Feedback Sandwich, common
in patient-physician communication literature
adapted by Lyuba Konopasek, MD, for use in
feedback settings.
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Ask
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• Ask learner to assess own performance first
• What went well and what could have gone better?
• What were their goals?
• Have they ever seen a patient like this before?
• Begins a conversation
• Assesses learners level of insight
• Useful for second-hand feedback

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Tell
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• Tell what you observed diagnosis and explanation
• React to the learners observation
• Feedback on self-assessment
• Include both positive and corrective elements
• I observed.
• Give reasons in the context of well-defined
  shared goals

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Ask (again)
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• Ask about recipients understanding and strategies
  for improvement
• What could you do differently?
• Give own suggestions
• Perhaps even replay parts of the encounter show
  me
• Commit to monitoring improvement together

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Limit the Quantity
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See One
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Checklist The Feedback Dialogue
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• Ask learner to assess own performance first
• What went well and what could have gone better?
• Tell what you observeddiagnosis and explanation
• React to the learners observation
• Include both positive and constructive elements
• Give reasons in the context of well-defined
  shared goals
• Regulate quantity
• Ask about recipients understanding and strategies
  for improvement
• What could you do differently?
• Give own suggestions
• Perhaps even replay parts of the encounter - show
  me
• Commit to monitoring improvement together

Adaptation of The New Feedback Sandwich, common
in patient-physician communication literature
adapted by Lyuba Konopasek, MD, for use in
medical resident feedback settings.
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Do one
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• Role plays
• Feedback on the feedback

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Teach one
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• Power Point Presentations targeted to residents
  for 1-hour noon conference, available on line
  (www.columbiacornellacgme.org)
• You may request support for co-teaching

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End with Ende
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• The important things to remember about feedback
  in medical education are that (1) it is
  necessary, (2) it is valuable, and (3) after a
  bit of practice and planning, it is not as
  difficult as one might think.
• Jack Ende,
  MD

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781.