Giving Performance Feedback in 5 Minutes

1. Giving Performance Feedback in 5 Minutes Carol Packard, Ph.D. Associate Dean for Academic Affairs June 18, 2010

2. Goals What makes for good feedback? What are the barriers? Outline an approach for providing effective feedback and evaluations Incorporate into a busy clinic setting

3. Teaching Encounters • Teachers must • Analyze quickly • Teach efficiently • Teach effectively Average 4.5 min * Presentation - 2.5 min. Inquiry - 1 min. Teaching - 1 min. * DM Irby, Presentation, Faculty Development Workshop, April 1999

4. Diagnosing performance Information learned? Information learned, (but not) remembered Information remembered, (but cannot) apply in context Information applied in particular context, (but not) transferable

5. 8 The Microskills • Seven skills (5 + 2) Easy to learn Efficient Evidence based Use day-to-day • Neher JO, et al, a Five-Step "Microskills" Model of Clinical Teaching, Journal of the American Board of Family Practice, Vol. 5, No. 4, pp. 419- 423. (1992)

6. Using microskills helps to: Identify teachable moment Diagnose the learner Provide specific feedback

7. Microskills Set and verbalize expectations Summarize in a sentence Generate hypotheses Get a commitment Probe for supporting evidence Teach a general rule Correct mistakes Reinforce what was right

8. Identifying the teaching moment: • Listen for cues When you hear a cue, use the appropriate Microskill

9. Scene 1

10. Summarize in One Sentence • Response • “Tell me the key points of the case in one sentence.” Cue: Scenario 1 The learner’s image of the case is unfocused

11. 1 2 Summarize in One Sentence Rationale: • Brings the “big picture” into focus • (cognitive representation) Helps learner focus on the causes, diagnosis rather than facts.

12. Generate Hypotheses Cue: The learner does not commit to a dx, or commits to a diagnosis without considering important alternatives... • Response: • Resist the urge to list those alternatives • Ask, "What other diagnoses should we consider?”

13. 1 4 Generate Hypotheses Rationale: • Prevents premature closure Teaches learner to consider alternatives Reveals learners knowledge

14. 1 4 Examples • “What other pathophysiologic processes could cause this presentation?” “What other diagnoses did you consider, and how did you exclude them?”

15. 1 4 Non-examples “What are the 12 causes of atrial fibrillation?"

16. Get a commitment • Response: • Resist the urge to fill in the verbal blank • Ask the learner what they think Cue: Learner presents the facts, and a diagnostic list, then stops ...

17. 1 6 Get a commitment Rationale Residents must learn to: Take responsibility for care • Put a case together

18. 1 6 Examples What do you think is the most likely diagnosis? WHY? "What lab tests should be ordered?"

19. 1 6 Non-Examples "Sounds like bronchitis to me." “What did you do at this point?”

20. 1 8 Probe for Supporting Evidence Cue: The learner commits to a diagnosis… and looks to you for confirmation. • Response: • Resist the urge to pass judgment on the opinion just stated • Ask, "What data support your assessment?"

21. 1 8 Probe for Supporting Evidence Rationale: • Learner must demonstrate problem solving skills Reveals learner’s knowledge and gaps "Thinking out loud" is a low-risk way for learners to make mistakes

22. 1 8 Examples "What led you to that conclusion?" "Why did you choose that medication?“ “Are there any findings that are left unexplained by your diagnosis?”

23. 1 8 Non-examples "I don't think this is appendicitis. Help the learner to reach this conclusion Then give feedback on the process

24. Your assessment process: Summarize in one sentence Generate hypotheses Get a commitment Probe for supporting evidence

25. Teach a general rule Cue: There are gaps in the learner's ability to apply knowledge • Response: • Teach useful, generally transferable principals • Don't mini-lecture

26. Teachable Moment A medical student is starting a new clinical rotation. Review the film clip that will be shown to you. http://www.med-ed.virginia.edu/courses/fm/precept/module4/m4p2.htm • (setting expectations) • Discuss the strengths and weakness of these student- resident encounters using the One-minute preceptor model.

27. Correct mistakes Cue: The learner demonstrates a misunderstanding or error • Response: • Ask directive questions • Give corrective feedback

28. 2 2 Correct mistakes Rationale: • Don’t assume that learners recognizes the mistake Mistakes left uncorrected will be repeated Learners who are aware of a mistake are in a "teachable" state Especially true for “professionalism” errors

29. 2 2 Examples “ I know it sometimes feel like you don’t contribute significantly to morning rounds, but it is critically important that you know the background of each patient’s case. Therefore, I expect you to be on time. • “This may be acute gout, but you can't exclude septic arthritis unless you tap the joint.”

30. 2 2 Non-examples • "You did what?!" "Those lab tests were completely unnecessary.”

31. Reinforce what was right • Response: • Give reinforcing feedback • Avoid general praise • Focus on the specific behavior Cue: A learner handled a situation very effectively

32. 2 4 Reinforce what was right Rationale: • Learners may not know what is right Unless reinforced, competencies may never be established Recognizing good performance builds respect, confidence

33. 2 4 Examples • ”You obtained cultures before starting antibiotics. This will allow us to select the most effective treatment.“ "You identified poor nutritional status in your problem list, and addressed it in your plan." • Professionalism?

34. 2 4 Non-examples “ok. " "You did that skin biopsy very well." "Good job!"

35. 3 3 One Minute Preceptor • Set &verbalizeExpectations Assess Reflect • Summarize in a sentence • Create hypotheses • Get a commitment • Probe for evidence • Make time to reflect • Give feedback • Provide opportunity for improvement Teach • Provide feedback • Teach general rules • Correct mistakes • Reinforce right

36. 2 5 Feedback Feedback Feedback Learners want to know how they are doing Surveys show they do not remember getting enough feedback on their performance

37. Does the learner always recognize feedback? Informal setting Residents often only recognize feedback in a formal “sit down” session. Rushed setting May not process “feedback of the fly” without reinforcement Stressed setting If attending sounds frustrated or abrupt, learner may fixate more on tone than content. Contradictory message Ending the feedback with a general “good” may confuse or even negate prior feedback. End with last thing you want the learner to remember.

38. 2 5 Giving feedback: State that you are going to give feedback Involve the learner in the process Use neutral, non-judgmental language Focus on the behavior, and the learning goals, not the person

39. 2 5 Feedback vs. Evaluation Feedback: Ongoing; provided day-to-day Formative-help learners direct their efforts • Evaluation: • Provided at the end of a course of study • Summative- a judgment relative to standards

40. Comparing Feedback and Evaluation Sessions

41. MSPE (“dean’s letter”) vs feedback to student

42. 3 3 In summary: One Minute Preceptor • Set &verbalizeExpectations Assess Reflect • Summarize in a sentence • Create hypotheses • Get a commitment • Probe for evidence • Make time to reflect • Give feedback • Provide opportunity for improvement Teach • Provide feedback • Teach general rules • Correct mistakes • Reinforce right

43. Reflection How do you integrate these processes into a busy clinical environment?????

44. Thank you from the UICOMP learners And Peoria community!