Providing Effective Feedback

1. Providing Effective Feedback Faculty Professional Development SeriesPerelman School of MedicineSeptember 8, 2011 Jennifer R. Kogan, M.D. Lisa M. Bellini, M.D. Department of Medicine

2. Workshop Objectives • Define feedback • Recognize importance of feedback • Identify barriers to feedback • Discuss characteristics of effective feedback • Practice providing feedback using the Ask-Tell-Ask method

3. What is feedback?

4. Feedback: Definition “Specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance.” “Feedback is an assessment for learning rather than an assessment of learning.” Van der Ridder MJM, Med Educ 2008;42:189-97.

5. Feedback Conveys information Formative Current performance Neutral (verbs & nouns) Foster learning Evaluation Conveys judgment Summative Past performance Normative statements (adjectives and adverbs) Certification Feedback vs. Evaluation

6. What Do They Have in Common?

7. How Do People Become Experts? • Deliberate practice • Working on well defined tasks • Informative feedback • Repetition • Self-reflection • Motivation • Endurance Ericsson KA et al. The role of deliberate practice in the acquisition of expert performance. Psych Rev.1993. 100(3):363-406.

8. Miller’s Pyramid EXPERT Novice NOVICE

9. Trends in Medical Education2000-present • Structure/Process • Content • Knowledge acquisition • Idiosyncratic • Single subjective measure • Norm referenced evaluation • Emphasis on summative Fixed length, variable outcome Competency Based Education • Competency Based • Outcome • Knowledge application • Intentional practice • Multiple objective measures • Criterion referenced • Emphasis on formative Variable length, fixed outcome Caraccio et al 2002

10. Trends in Medical Education2000-present See one, do one, teach one • Effective Supervision • Helps trainees gain skills faster and behavior change more quickly • Relationship quality affects effectiveness • Self-supervision not effective • Better supervision associated with improved patient safety and quality of care Patient Safety Increased supervision Kilminster; Med Teach 2007

11. “. . . closer supervision leads to fewer errors, lower patient mortality, and improved quality of care. . . These recommendations are designed to ensure that we better train today’s residents so they can better treat tomorrow’s patients.” 2010 Common Program Requirements

12. Which of the following individuals said the following: “You can observe a lot just by watching?” • Sir William Osler • Hippocrates • Abraham Flexner • Lawrence Peter Berra • Lower Merion School District Administration • Benjamin Franklin

13. Which of the following individuals said the following: “You can observe a lot just by watching?” • Sir William Osler • Hippocrates • Abraham Flexner • Lawrence Peter Berra • Lower Merion School District Administration • Benjamin Franklin

14. Benefits of Feedback: Learners • Develop expertise • identify strengths/weaknesses without academic penalty • practice and improve knowledge and skills • define teachers’ expectations

15. Benefits of Feedback: Teachers • Strongly associated with teaching ratings • Actively recognize student progress and achievement • Evaluate and modify coursework/teaching

16. Clinical Education Without Feedback • Missed learning opportunities • Learner insecurity about abilities • Inaccurate perception of performance • Disappointment and surprise with final evaluations

17. What Are The Barriers To Feedback?

18. Barriers • Time constraints • Limited information about learner performance • Absence of standards of competence • Inadequate knowledge of tenets of effective feedback • Giving negative feedback • Concern about undesirable consequences for learner (self-esteem) • Concern about undesirable consequences for teacher

19. Giving Feedback about Clinical Skills

20. What are Principles of Effective Feedback?

21. 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

22. Inpatient Pre-rounds Post-rounds counseling Discharge instructions ED encounters Part of admission Family meeting OR/procedures Outpatient First 5 minutes of encounter Part of physical exam Counseling Snapshots

23. Structured Approach to Deliver Feedback

24. The New Feedback Sandwich Ask Tell Ask Konopasek L 2009; New York Presbyterian

25. Set the Stage • Establish goals upfront: yours & the learners • Establish expectation of continuous feedback • Create environment conducive to feedback • Private, quiet, close to event, not post-call • Use the “F” word • Start session by telling learner: “This is your feedback”

26. Ask • Ask learner to assess own performance • Begins a conversation – an interactive process • Assesses learner’s level of insight and stage of learning • Promotes reflective practice

27. Tell • Tell what you observed • Include both positive and corrective elements • “I observed….” • React to the learner’s observation • Feedback on self-assessment • Provide action plan (suggestions for how to improve) ** Remember: limit constructive feedback to no more than 2-3 (max 4)

28. Ask (again) • Ask about recipients understanding and strategies for improvement (action plan) • What could you do differently? • Give own suggestions • Commit to monitoring improvement together

29. Benefits of Ask-Tell-Ask • Learner centered • Active and interactive • Avoids assumptions or judgment • Promotes reflection • Branch J et al. Feedback and Reflection: Teaching Methods for Clinical Settings. Acad Med. 2002;77:1185-8. v

30. A Model of Feedback • Where am I going (What are the goals)? * “feed-up” • How am I going (What progress is being made toward the goal)? * “feed back” 3) Where to next (What activities need to be undertaken to make better progress)? * feed forward” Hattie and Timperley. Review of Educational Research. 2007;77:81-112.

31. Feedback Role Plays

32. Scenario #1 Faculty You have been working with a medical students for four days. 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.

33. Scenario #1 Medical student You are four days into your rotation. It 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 and you are having problems piecing it all together.

34. Scenario # 2 Faculty It is the midpoint of your four-week rotation with a pediatric 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.

35. 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.

36. Skill/No Will Skill and Will Excite Delegate SKILL No Skill/ Will No Skill/No Will Direct Guide WILL

37. 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.

38. 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 . . .

39. Scenario # 4

40. Recommended Reading • Archer JC. State of the science in health professional education: effective feedback. Mewdical Education. 2010; 44:101-8. • Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-81. • Hattie J, Timperley H. The power of feedback. Review of Educational Research. 2007;77:81-112. • Van de Ridder JMM, Stokking KM, McGaghie WC, ten Cate OTJ. What is feedback in clinical education? Medical Education. 2008;42:189-97.