Learner Centered Feedback – ADAPT Part 1

1. Learner Centered Feedback – ADAPT Part 1 Shannon Waterman, MD Swedish Family Medicine Cherry Hill Seattle, Washington

2. Objectives • Characteristics of effective feedback • Review ADAPT model of giving feedback • Ask-Discuss-Ask (think sandwiches…) • Skills practice and cases

3. Poll Faculty Experience

4. Poll Training

5. Feedback Is Not Evaluation What words of feedback might he need? What evaluation might he get? Is generic praise helpful?

6. Feedback vs. Evaluation Feedback Evaluation Balanced Looks toward the future Coaching Red ink in the margin One-way Reviews recent past All-Star Voting Final grade

8. Poll Realms of feedback

9. Elements of Effective Feedback 1. Expected, timely and routine 2. Based on first-hand information 3. Descriptive rather than evaluative 4. Focused on issues learner can control 5. Specific and concise 6. Private* 7. Reciprocated Ende J. Feedback in Medical Education. JAMA. 1983

10. What do we know about feedback? • Learners want more feedback • Learners and faculty perceive feedback differently • Feedback can be effective • Communicating effective feedback is complex • Direct observation is a pre-requisite to feedback

11. Poll Barriers?

12. Barriers to feedback • Vulnerability (want to be liked, avoid conflict) • Limited time actually observing (“table rounds”) • Poor observers, unable to “unpack” our observations • Limited time • Different capabilities of learners at different levels • Myth (generational, hold-over among Baby Boomers?) • Adult learners do not need feedback. • “I never got any feedback, so why should you?”

13. Medicine’s Learning Culture • Multiple supervisors for short periods of time • Faculty often asked to evaluate AND coach • Faculty asked to evaluate too many specifics • Limited opportunities for direct observation of learners in action • Culture values efficiency and autonomy • Complexities of a combined working and learning environment

14. ADAPT model Prepare Observe Ask Discuss Ask Plan Together

15. ADAPT model Prepare Observe Ask Discuss Ask Plan Together

16. Poll Bedside Rounds

17. Poll Opportunities for observation & Frequency

18. Abridged history of feedback The Old Feedback Sandwich The New Feedback Sandwich Praise / Criticism / Praise Ask / Tell / Ask Ask/ Discuss /Ask

19. Ask – Discuss – Ask • Ask learner to assess own performance. • Have you seen a patient like this before? • What went well? • What couldhave gone better?

20. Ask - Discuss- Ask • Discuss what you or the learner observed • React to the learner’s observation • Feedback on self-assessment • Include both affirmative and corrective elements • “I observed….” • Give reasons in the context of well-defined shared goals • “You want to become more skilled with cervical exams...”

21. Ask – Discuss – Ask • Ask about learner’s understanding. “Teach-back.” • Explore strategies for improvement. • “What could you do differently?” • Replay relevant part of encounter • “Show me how you might phrase…”

22. General Strategies • Reinforce positive behavior – catch them doing something right • “I appreciated how you incorporated the family into your presentation this morning.” • Redirect negative behaviors • “I’d like to give you feedback on your presentation. When there is a family present on rounds, be sure to start with an introduction of the team.”

23. Feedback: Be Descriptive • Vague: “You relate well to patients.” • Specific: “How did that go for you? When you asked who would care for her dog when she is admitted for surgery, I saw her visibly relax. Your caring insight helped change the whole tone of the conversation. Did you notice that change in her affect? Was that a natural thing for you to do?”

24. Environment provides feedback • Patient and patient’s family • Peers (student, residents) • Staff and consultants • Own personal perception*

25. How good are we? • Terrible. • Huge discrepancy between perception of attending giving feedback and resident or student learners in multiple specialities.

26. Why learners don’t “hear” feedback? • Receiver doesn’t: • Recognize feedback when it is given • Understand the message • Reflect on the meaning • Giver: • Doesn’t make time to give feedback • Gives feedback in public setting (shaming, humiliating) • Vague examples • Interplay between giver/receiver: • Heard and taken as personal criticism…personality or style conflict…distrust based on gender/culture/race/power

27. ADAPT model Prepare Observe Ask Discuss Ask Plan Together

28. Objectives • Characteristics of effective feedback • Review ADAPT model of giving feedback • Ask-Discuss-Ask (think sandwiches…) • Skills practice and cases

29. Your feedback is welcomed! Shannon.Waterman@Swedish.org

30. Cases – Resident inpatient service • You sit down with the intern for a feedback session at the end of your inpatient week. • You begin with some of the things she has done well, then turn to the areas she needs to work on. Team feedback (and evaluation) suggests she is performing at a solidly average level. • You bring up several patients whose past medical history she had not investigated adequately and comment that she needs to be more succinct in her write-ups.

31. Cases – Giving intern feedback • The resident gets angry. “There is never anytime for me to actually spend with the patients.” • She considered it great time management and commitment on her part that she would wake patients up at 4am to get a more complete history. • She also feels that you have not helped her or understood that she was taught to “write long notes.”

32. Cases – Giving student feedback • What went wrong? How could you have made this a more effective evaluation session? • “ You need to continue working on your efficiency. You improved substantially by keeping a list and learning to prioritize better, but you still need to work on shortening your notes.” • Is this good feedback? • Is this effective feedback?