Effective Feedback in Medical Education Workshop

1. PROFESSIONAL DEVELOPMENT • Basics Program for New Faculty – Day 1: October 3, 2013 • Presenters: Sarah Fleming MD CCFP, Gweneth Sampson MD CCFP FCFP MScCH • Facilitators: Helen Batty, Allyson Merbaum,Sarah Reid, Michael Roberts, GwenethSampson, Monica Sethi, Barbara Stubbs Strategies for Effective Feedbackin Medical Education

2. This set of slides is adapted for DFCM Open. You can download these slides at www.dfcmopen.com/item/effective‐feedback-in-meded. • Find a handy one-page reference about giving feedback at www.dfcmopen.com/item/giving-feedback-basics.

3. The objectives of the “one-pager”, which includes a list of references, are as follows: • 1. Describe the role, models and characteristics of constructive feedback in education. • 2. Understand some of the common challenges and barriers to effective feedback, including the role of student self-assessment.

4. Learning Objectives • Participants will be able to: • Describe the role, models, and characteristics of constructive feedback in education • Understand some of the common challenges and barriers to effective feedback, including the role of student self assessment • Demonstrate feedback techniques

5. Overview of Workshop • Background Information • DVD: Resident scenario • Feedback Role Play • Feedback Checklist • DVD: Small Group Exercise • Summary

6. Key Messages • Trainees state that feedback is the main item they don’t get enough of in teaching sessions (Hewson and Little,1998) • The process of giving feedback is as important and structured as taking a good history • Focusing on attaining a comprehensive student self-assessment and establishing a dialogue are keys to good feedback (Ende, 1983; Ramani & Krackov, 2012) • We need to give better feedback - not necessarily more

7. Feedback: Definitions • Feedback is the sharing of information on actual performance to help guide the student’s future performance toward a desired goal (Ramaprasad, 1983) • It is essential to learning • It requires a sample behaviour, a clear model of the desired behaviour, and a demonstration of the difference between the two

8. Types of Feedback Formative • Aimed at improvement • Gathered to inform change • Eg. Field Notes Summative • After-the fact • Evaluation • Judgment • Eg. End of Rotation Evaluations (ITERS) Feedback is most useful when provided during a formative evaluation (Sadler,1989)

9. Why Give Feedback? “Feedbackcan change physicians’ clinical performance when provided systematically over time by an authoritative credible source” (Velosky et al., 2006)

10. Feedback Models • Sandwich Technique“positive/negative/positive” • Pendleton Method (Cantillon and Sargeant, 2008) • Relative Ranking System • EFPO “6 Step” Model (Educating Future Physicians of Ontario)

11. EFPO Model of Feedback(Six Step) • Teacher observation of student behaviour or work • Ask the student for their self-assessment • Describe the desired behaviour • Ascertain that the student understands thedifference between current behaviour and desired behaviour • Elaborate a plan to close the gap (an educational prescription) • Follow-up on improvement Merrilee Brown, Brian Hodges, J.Wakefield, Effective Feedback, 1995

12. An Example - Parallel Parking • Observe student parallel parking (too far from the curb) • Ask for self assessment - “How do you think that went?”“What did you do well?”… “Is there anything that didn’t go as well as you had hoped?” • Describe desired behaviour - “You did a great job at checking the space around the car. Next time I would recommend parking closer to the curb… Indeed, this can be tricky sometimes” • Check if student understands the difference between current parking and desired parking – “What do you think about my suggestion of parking closer to the curb?”“How much closer would you like to be next time?”…“Yes, two feet closer sounds good”

13. An Example - Parallel Parking • Make a Plan to close the gap - “Is there anything that you can think of that may improve it for next time?” … “ I agree, and you could also try slowing down the car as you reverse. Why don’t you watch me park, then practice this again for 10 minutes every day” • Follow-up on improvement - “I will observe you park again in 3 days and we can touch base to see how things are going”

14. Characteristics of Effective Feedback Solicited Descriptive Focus on modifiable behaviours Limited – 1 or 2 points Well-timed Dialogue Authentic Specific Verifiable Create a supportive environment Provided regularly over time Balanced

15. Characteristics of Effective Feedback: CORBS Characteristics of Effective Feedback: • Clear • Observed (and Owned) • Regular / Restricted • Balanced • Specific

16. Possible Barriers to the Provision of Effective Feedback • Little or no instruction on how to give feedback • Fear of damaging relationship with learners • Hierarchy issues between teacher and learner • Cultural context issues • Students’ ability to self-assess

17. Self-Assessment of Competence:Why is it an important skill? • Leads to increased motivation and improved knowledge, communication and performance (Evans, 2002) • The ability to accurately assess one’s own strengths and weaknesses is the first step in self-directed learning (Boud, 1990) • Physicians are responsible for their own continuing medical education

18. Self-Assessment of Competence: Are we good at self-assessment?

19. Self-Assessment of Competence: Self assessment high (Dunning and Kruger, 1999) Risk group Risk group Burnout potential Vicious cycle of incompetence Competence low average high

20. Self-Assessment of Competence: Can we improve our self-assessment skills?

21. Self-Assessment of Competence: (Dunning and Kruger, 1999) Self assessment high Risk group Risk group Improved competence creates improved self assessment skills Burnout potential Competence low - insight- ability to use feedback average high

22. Self-Assessment of Competence: Self assessment high (Dunning and Kruger, 1999) Improvement in self assessment after viewing “benchmark” videos (Martin et al., 2004) low average high Competence

23. Feedback and Reflection • Feedback  self-assessment  reflection • Although self-assessment is often inaccurate, self assessment skills can be learned • Reflection and self-assessment are critical for lifelong learning • Reflection accelerates learning and improves the depth of understanding (Westberg & Jason, 2001) • Reflective practioners are likely to provide better patient care

24. Useful Rules for Role-Play and Debriefing • Preferable to recruit volunteers, not assign roles • Refusal always allowed • Time out whenever needed “T” • Role players debrief first • most anxiety provoking roles first (no interrupting) • may be given a reasonable time limit in advance • Role players discuss first • with each other • ask observers questions for specific feedback and advise them of areas “off limits” for comment • Observers provide specific careful feedback following guidelines • use data from field notes “quotations” etc. • respect requests and limitations set by role players • Time keeper keeps track of start and stop times Batty’s Rule: 1 minute of role playing  2 to 10 minutes of debriefing

25. Large Group Debrief • What strategies worked? • What was a challenge? • What will you try in future?

26. Wrap-Up - Review of our learning objectives • Participants will be able to: • Describe the role, models, and characteristics of constructive feedback • Understand some of the common challenges • Demonstrate feedback techniques How Did We Do?

27. Practical Tips • Label this as “Feedback” • Think about Timing and Privacy • Link to Learner’s Objectives • Provide Opportunity for Change • Get Feedback on your Feedback • Follow-Up

28. Key Messages • Feedback is crucial to the improvement of performance, self assessment skills and reflective practice • Process = 6 step EFPO model: observe, student self-assessment, describe behaviour, describe the gap, make an educational plan and follow up • CORBS: Clear, Observed, Regular, Balanced, Specific • Just do it (and label it!)

29. References • Branch W and Paranjape A (2002). Feedback and Reflection: Teaching Methods for Clinical Settings. Academic Medicine 77 (12): 1185-1188 • Cantillon P and Sargeant J (2008). Giving feedback in clinical settings. BMJ 337:a1961. • Davis D, Mazmanian P, Fordis M, Van Harrison R, Thorpe K, Perrier L (2006). Accuracy of Physician self-assessment compared with observed measure. JAMA 296(9):1094-110 • Dunning D, Kruger, J (1999). Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments. Journal of Personality and Social Psychology 77 (6): 1121-34. • Eva K and Regehr G (2013). Effective feedback for maintenance of competence: from data delivery to trusting dialogues. CMAJ April 2; 185:463-464 • Evans A, McKenna C, Oliver M. (2002). Self-assessment in medical practice. J R Soc Med 95:511-513. • Hewson MG, Little ML. (1998). Giving feedback in medical education: Verification of recommended techniques. J Gen Intern Med 113:111–118.

30. References • Mann K, Gordon J, Macleod A. (2007) Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Edic Theory Pract  2007;14:595-621. • Martin D, Regehr G, Hodges B, McNaughton N. (1998) Using videotaped benchmarks to improve the self-assessment ability of family practice residents. Acad Med. Nov 73(11): 1201-6. • Ramani S, Krackov S. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher 34:787-791. • Ramaprasad A (1983) On the definition of feedback. Behav Sci 28:4-13. • Sadler, DR (1989) Formative assessment and the design of instructional systems. Instructional Science 18:119-144. • Sandars J. (2009). The use of reflection in medical education: AMEE guide 44. Med Teach 31:685-95. • Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. (2006). Systematic review of the literature on assessment, feedback and physicians' clinical performance: BEME Guide No. 7. Med Teach. Mar;28(2):117-28. • Westberg, Jane & Jason, Hilliard. (2001) Fostering Reflection and Providing Feedback, New York: Springer Publishing Co.

31. Thank You!