Providing Effective Feedback

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Providing Effective Feedback

• Faculty Professional Development
  SeriesUniversity of Pennsylvania School of
  MedicineSeptember 10, 2008
• Jennifer R. Kogan, M.D.
• Lisa M. Bellini, M.D.
• Department of Medicine

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Workshop Objectives

• Distinguish between evaluation and feedback
• Discuss principles of effective feedback
• Identify barriers to feedback
• Identify strategies to increase feedback and
  improve skills delivering feedback

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Feedback vs. Evaluation
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• Feedback
• Conveys information
• Formative
• Current performance
• Neutral
• (verbs nouns)
• Foster learning

• Evaluation
• Conveys judgment
• Summative
• Past performance
• Normative statements
• (adjectives and adverbs)
• Certification

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Benefits of Feedback

• Assist learners to
• evaluate knowledge, practice skills
• define teachers expectations
• identify strengths/weaknesses without academic
  penalty
• remedy deficiencies
• Assist teachers to
• evaluate and modify coursework and teaching
• recognize student progress and achievement

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Clinical Education Without Feedback

• Missed learning opportunities
• Student insecurity about abilities
• Inaccurate perception of performance
• Disappointment and surprise with final
  evaluations

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• Principles of
• Effective Feedback

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Principles of Effective Feedback

• Related to agreed upon goals
• Specific
• Reinforce positive outcomes and behaviors
• Provide guidelines for improvement
• Quantity regulated, limited to remediable
  behaviors
• First hand, objective information
• Timely
• Descriptive not evaluative language
• Accompanied by explanations
• Includes an action plan

Ende J. JAMA. 1983 250 777-781
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• Feedback during clinical rotations appears to be
  a rather intractable problem
• in medical education

Irby DM. Acad Med 1994 69333-42
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• What Are The Barriers To Feedback?

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What Are Barriers to Feedback?

• Time constraints
• Limited information about learner performance
• Absence of standards of competence
• Inadequate knowledge of tenets of effective
  feedback
• Giving constructive feedback
• Concern about undesirable consequences for
  student or teacher

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"You can observe a lot just by watching."
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"You can observe a lot just by watching."
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What are barriers to observing students/
residents with patients?
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Strategies to Increase Observation

• Frequent snapshots
• Pre-rounds
• First 5 minutes of the outpatient encounter
• Post-rounds counseling/discharge instructions
• Observe exam

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The Rules for Observation

• Tell learner you will be coming into the visit
• Be a fly on the wall
• avoid interrupting learner/patient dialogue
• avoid eye contact with the patient
• avoid interruptions

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Structured Approach to Deliver Feedback
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Set the Stage

• Create environment conducive to feedback
• Elicit learners goals beginning of rotation
• Establish expectation of continuous feedback
• Start session by telling learner this is your
  feedback

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Conduct the Feedback Session

• Elicit learners self-assessment
• - what was done well
• - what needs improvement
• Provide feedback positive and negative
• Check for understanding
• Develop action plan/ determine how to monitor
  progress

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Follow-Up

• Meet again
• Ensure action plan developed/in progress

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The Feedback Sandwich
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Feedback Role Plays
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Scenario 1

• Faculty
• It is the end of the first week of a two week
  rotation
• and you are about to meet with the medical
  student
• who has been rotating with you. The medical
  student is
• enthusiastic, hard working and interested in
  learning. The
• student seems to enjoy working with patients, is
  timely and is
• always asking to see additional patients. You
  are concerned
• that the student is having difficulty presenting
  a coherent,
• organized history and physical exam and have
  noticed that
• the student's notes are similarly disorganized
  with an
• incomplete assessment and plan. You believe the
  student's
• knowledge base is borderline.

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Scenario 1

• Medical student
• It is the end of the first week of a four week
  rotation. This is
• your second core clerkship. You think that you
  have been
• doing a good job. You really like seeing patients
  and are
• eager to learn. You have tried to be enthusiastic
  and a team
• player. The office/ward has been very busy and
  learning how
• to do a focused patient visit has been a bit hard
  since in
• Introduction to Clinical Medicine you had 45
  minutes to see a
• patient and now you only have 15 minutes.

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Scenario 2

• Faculty
• It is the midpoint of your four-week rotation
  with a medicine
• core clerkship student. You had told the medical
  student at
• the beginning of the rotation that you would have
  a mid
• rotation feedback session. The medical student is
  very bright
• and has a superior fund of knowledge. He is able
  to perform
• a focused history and physical exam, synthesize a
  problem
• list, assessment and plan. However, the student
  has arrived
• late on three occasions and requested to leave
  early another
• day. Some of the nurses felt he has been curt and
  abrasive.
• The student once got visibly annoyed when
  speaking with a
• nurse earlier in the week.

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Scenario 2

• Medical student
• It is the midpoint of your four-week rotation and
  you and
• your attending are meeting for a planned feedback
  session.
• You haven't been too interested in this rotation
  - you are
• pretty certain that you are going into Radiology.
  You believe
• that you have done a pretty good job of seeing
  patients and
• have tried to come up with differential diagnoses
  for the
• patients you see. But overall, you are pretty
  bored and are
• looking forward to your next rotation which you
  think will be
• much more pertinent to your future career goals.

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Scenario 3

• Faculty
• You are on morning rounds with your resident,
• intern and medical student. The team had a very
• busy night and admitted several sick patients.
  One
• patient was admitted with dyspnea. The patient
  was thought
• to have an asthma flare and was given nebulizers.
  Oxygen
• saturations levels were checked throughout the
  night. A CXR
• was not done and no oxygen was ordered. While at
  the
• bedside you notice the oxygen saturation of 85
  and the
• patient in respiratory distress.

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Scenario 3

• Intern
• You have just finished a very busy call night.
• You did not have time to see all of your patients
• before attending rounds. You get to the bedside
  of
• this patient and begin your presentation. As you
• begin talking about the physical exam, the
  attending
• picks up the patient flow sheet and notices the
• hypoxemia. The attending enters the room to find
• the patient in respiratory distress . . .

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Tools to Increase Feedback
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Feedback Toolbox

• Mid rotation feedback forms
• Read/distribute feedback article
• Mini-CEX or encounter cards
• Learners contract
• Prime learners for feedback
• review tenets of feedback at orientation
• prompt students during course
• teach students how to ask for it