A Donkeys TailFeedback Webinar 2013Shannon Waterman, MDSwedish Family Medicine Cherry HillSeattle, Washington

ObjectivesWhat is feedback?Examples of effective feedbackAsk-Tell-Ask (think sandwiches)Skills practice and cases

TED: Bren Browns The Power of Vulnerability

Pause for pollTeaching

Pause for pollTraining

Feedback Is Not EvaluationWhat words of feedback might he need?

What evaluation might he get?Is generic praise helpful?

Pause for pollRealms of feedback

Feedback vs. EvaluationFeedbackEvaluationBalanced

Looks toward the future

Coaching

Red ink in the marginOne-way

Reviews recent past

All-Star Voting

Final grade

Pause for pollYour experience?

Elements of Effective Feedback1. Expected, timely and routine2. Based on first-hand information3. Descriptive rather than evaluative4. Focused on issues learner can control5. Specific and concise6. Private7. ReciprocatedEnde J. Feedback in Medical Education. JAMA. 1983

Pause for questions and pollBarriers?

Barriers to feedback

Vulnerability (want to be liked, avoid conflict) Poor observers, unable to unpack our observations Limited time Different capabilities of learners at different levels Myth (generational?) Adult learners do not need feedback. I never got any feedback, so why should you?

How good are we?Surgery86.2% attendings felt feedback given often/always after incident vs 12.5% residents

85.7% attendings felt feedback on specifics vs 54.2% of residents

96.6% attendings felt feedback started with positivesvs 54% of residents

69% attendings felt they gave complete feedback vs 16.7% of residentsLiberman et al. Surgery residents and attending surgeons have different perceptions of feedback. Medical Teacher. 2005:27(5), 470-72Thanks to Uniformed Services University, Jessica T Servey, Lt Col, USAF, MC. Director, Family Medicine Clerkship

How good are we?Internal Medicine8% residents very satisfied with feedback80% stated never or infrequently received corrective feedback

Family MedicineInpatient feedback only 14% of comments specifically targeted

Emergency MedicineAttendings more satisfied with timeliness and content than residentsAttendings rate as constructive more often than residentsSostok M, Coberly L, Rowan G. Feedback Process between Faculty and Students. Acad Med. 2002;77(3), 267.

How good are we?MSIII students, Internal Med rotation at Ohio VA1 hour bedside history & physical observed (58 sets)Feedback given, questionnaire completed

Perception of time spent on feedback similar (26 minutes)

Number of items covered: 3.3 by faculty report and 2.7 by student report

Only 34% agreement in content of the feedback

Sostok M, Coberly L, Rowan G. Feedback Process between Faculty and Students. Acad Med. 2002;77(3), 267.

Abridged history of feedbackThe Old Feedback SandwichThe New Feedback Sandwich

Praise / Criticism / PraiseAsk / Tell / Ask

Ask - Tell - AskAsk learner to assess own performance.Have you seen a patient like this before?What went well?What could have gone better?

Cases Why Ask?Reflecting on encounters in medicine can deepen our satisfaction and engagement with what we are doing.It can help us recognize the profundity of what we do. Developing your ability to reflect may decrease burnout.

Ask - Tell - AskTell what you observed React to the learners observationFeedback on self-assessment

Include both affirmative and corrective elementsI observed.

Give reasons in the context of well-defined shared goalsYou want to become more skilled with cervical exams...

Ask - Tell - Ask

Ask about learners understanding. Teach-back.

Explore strategies for improvement. What could you do differently?Replay relevant part of encounterShow me how you might phrase

Focus on the behavior you want to see

General StrategiesReinforce positive behavior catch them doing something rightI appreciated how you incorporated the family into your presentation this morning.

Redirect negative behaviorsId 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.

Feedback: Be specificVague: You seem bored on rounds.

Specific: Sometimes you leave the room before we finish discussing a case. I think it is important for all of us to hear about other cases for education and cross-cover.

Vague: You seem disorganized.

Specific: On work rounds it might be more efficient to see all the patients, then write orders, review x-rays and then talk to consultants.

Feedback: Be SpecificVague: Be more careful with the reflex hammer.

Specific: What did you learn from your exam? Here, let me demonstrate how I do the reflex exam and I think youll be able to pick up more subtle differences. Does that seem like a technique you could use with your next patient?

Feedback: Be DescriptiveVague: 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?

Environment provides feedbackPatient and patients familyPeers (student, residents)Staff and consultantsOwn personal perception*

Why learners dont hear feedback?Receiver doesnt:Recognize feedback when it is givenUnderstand the messageReflect on the meaningGiver:Doesnt make time to give feedback Gives feedback in public setting (shaming, humiliating)Vague examplesInterplay between giver/receiver:Heard and taken as personal criticismpersonality or style conflictdistrust based on gender/culture

Take performance to the next levelTell them what theyre doing right (they may have done it on accident!)Positive, reinforcing feedback can be followed with restating new goals to reach a new level.For any student or resident, the end of one rotation is the start of the next. Help them define their next goals.

Red Flags Take Action!Behavior that is unsafe, unethical, unprofessional should be addressed immediately.Discuss with learner promptly and privately.Notify attending. No Surprises policy.Note learners progress and improvement. Comment on this in evaluation, if appropriate.

ObjectivesWhat is feedback?Examples of effective feedbackAsk-Tell-Ask (think sandwiches)Skills practice and cases

TED: Bren Browns The Power of Vulnerability

Feedback is welcomed!

Cases Resident inpatient serviceYou 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. 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.

Cases Giving student feedbackThe resident gets angry. There is never anytime for me to see 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 for the attending.

Cases Giving student feedbackWhat 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?

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Credit to Marah Gotschick for pin the tail on the donkey concept (was Chief at Childrens, now practicing pediatrician in Anchorage.)Use pin the tail 3 versionsOpportunities to try out observing and giving specific feedback

*Coaching: In 2011 Atul Gawande, a surgeon, wrote about the role of advanced practice coaching.http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande*Even expert drivers with years of experience can benefit from this sort of feedback.**Routine, iterative feedback takes an historically high stakes experience and makes it low-stakes. No longer fight or flight sensation of being called into principals office.

Descriptive try to reserve judgement. Say what it is you see. Hold off on theorizing about agendas or motivations.

Specific few things as unhelpful as generic praise. Becomes a pet peeve for many learners. Good job.*Giving effective feedback is NOT an innate skill for most physicians

Brene Browns Power of Vulnerability TED talk.

Lack of appropriate feedback leads to: Loss or neglect of desired learningRetention of incorrect learning or bad habitsA false sense of competence

*Demo both

**Begins a conversationAssesses learners level of insight Promotes reflective practice

Establish expectations at the beginning your preceptors/faculty will tell you about things youre doing well and things that you can improve upon. That is feedback. It may not come with that label, but thats what it is.

*Animations pause for suggestions before answers.***To improve accuracy of learners personal perception, you might ask them to pay attention to environmental cues rather than being directive about specific actions.

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