GIVING AND RECEIVING EFFECTIVE FEEDBACK Ann Hiott Barham

GIVING AND RECEIVING EFFECTIVE FEEDBACK Ann Hiott Barham, MD John L. Turner, MD Society of Teachers of Family Medicine Annual Meeting, Vancouver, BC April 26, 2010

Session Goals • Critique actual feedback • Examine the principles of effective feedback and evaluation • Review common traps and barriers in the evaluation & feedback process • Discuss feedback delivery models • Identify feedback common opportunities in family medicine education *Practical focus on written feedback

Feedback & Evaluation What words pop into your mind…

Non-Effective Feedback • Example 1___________ • Example 2 • • • Dr. X was a pleasure to work with. She will do well with whatever career path she chooses. I encourage him to continue to read (eat three square meals, breathe regularly and vote his conscience. )

Definitions • Feedback • The process by which the teacher provides learners with information about their performance for the purpose of improvement An Observation

Formative Feedback • Educator as coach “Jake, I think throwing 5 interceptions in a game is not going to help your career. ”

Definitions • Evaluation • Judgment rendered comparing the learner's performance to external standards with an intent to decide on promotion A Grade

Summative Assessment and Feedback • Educator as Judge

Effective Feedback • • Descriptive and non-judgmental Specific, Behavioral (what you did vs. who you are) Well-timed – synchronous, frequent Mixture of positive & corrective Includes learner reaction Anticipatory guidance Helps learners develop a personal feedback mechanism Ende, J 1983.

Levels of Feedback • Minimal • “Good job” • “I agree” • “I’m not so sure about that” • indicating approval or disapproval without explanation • Tell the learners that their performance was correct or incorrect • Agree or disagree • Nonverbal cues, nodding

Levels of Feedback, continued • Specific/Behavioral • “I agree that the murmur you heard was likely mitral valve prolapse” • You did a good job using non-jargon language and open ended questions with this patient. ” • Specifically indicating why a learner was correct or incorrect • Includes preceptor rationale for feedback • Give reasons, rationale for feedback • Offer suggestions

Levels of Feedback • Interactive • “How do you think you did with this patient? ” • “What did you struggle with? ” • Feedback eliciting learner self-evaluation of his/her performance • Give feedback on self-assessment • Agree on goals with learner • Develop an action plan • Allow the learner to react to the feedback

What Makes it Difficult to Give Good Feedback?

Negative Learner Reactions • Closed • Rationalizing • Disrespectful • Defensive/Attacking • Superficial/Patronizing Hosokowa, 2005

Barriers to Giving Feedback • • • I don’t want to be the bad person I don’t want to upset him/her I don’t want to make a big deal of it I don’t want to ruin his/her career I don’t want to end up in court Medio, F. 2005

Barriers to Giving Feedback • I (or others) may have contributed to the problem • He/she realizes it was wrong and won’t do it again • It’s too late in the program or year • I don’t like confrontation Medio, F. 2005

Traps to Avoid in the Feedback Process • Reviewing performance from an autobiographical perspective • “When I was a student…” • Basing judgment on extraneous factors • “She is trying hard; He’s a really nice person” • Becoming the target of shifted responsibility • When learners shift attention back to you/the program to derail your feedback

Traps, continued • Using only one assessment instrument and/or a single evaluator • Introducing bias – the “halo effect” • The learner can do no wrong/right; over generalizing performance • Creating artificial barriers or obstacles • “Senior-itis” • “He’s never going to do this in his practice setting”

Feedback Delivery Models

1 Minute Preceptor / Microskills Steps 1. 2. 3. 4. 5. Get a commitment Probe for supporting evidence Teach general rules Positive reinforcement Correct mistakes Neher et al 1992, Irby

Communicating Corrective Feedback: STEER • State what you saw/heard and WAIT • Teach nonjudgmental rule(s) to reinforce, correct behaviors • Encourage learner by identifying next steps • Elicit his/her reaction and plan to move forward • Repeat Arrange/Allow for second try

The Old Feedback Sandwich Praise Criticism Praise

The New Feedback Sandwich Ask Tell/Teach Ask Lyuba Konopasek, MD pediatric clerkship director at Weil-Cornell Medical College

Ask – Tell/Teach - Ask • ASK • What did you do well? • What did you struggle with • TELL / TEACH • Agree / Disagree • Focused Teaching (1 Minute PEARL) • ASK • WHAT and HOW can we (you and I) improve? • Demonstrate / Practice / Read ? ? ?

Feedback Opportunities …

Feedback Opportunities … • Precepting Admission Clinic • • • Procedures Deliveries Post call discussions Inpatient (beginning of week) Inpatient (end of a week) Teaching clinics Logician flag system Video tape review

Feedback Opportunities … • • • Video tape review Resident – Faculty meetings (not individualized) Hallway conversations / curb-sides Advisor meeting Formal Written Evaluations Rotation evaluations End of year faculty evaluations Staff evaluations Quarterly reviews

Feedback: What do you want to convey? • • • Your self-assessment is a key element Here’s what I see Here’s how to become even better I believe in your ability to do this I expect you to work on it I am here to help you

Feedback Case 1 • “Excellent senior resident, enthusiastic, professional, kind and considerate to his patients and his colleagues, hard working, and a team player. He has an excellent wealth of knowledge and always shares a teaching point with the team. He cares so much for his patients and spent as much time as his patient needs to make sure everything was done appropriately. Helped the first year residents on their inpatient service by teaching one to one through cases that they admitted to the inpatient service. I enjoyed working with him. ” What is good about this feedback? How could the feedback be improved?

Feedback Case 2 • Overall, it was good to see Resident X in an upper level role. He took this to heart. Made good suggestions and was appropriate with his position in the team. His knowledge base seemed very solid, and he was not as quiet as I expected him to be. What is good about this feedback? How could the feedback be improved?

Feedback Case 3 • “Resident X is a bright and astute clinician who can manage pts well. he directed the team with a low key authority. gentle, respectful bedside manner. I felt very confident that our pts' care would go well. My only criticism is that I would have liked to see more FORMAL teaching from Resident X and better awareness of the responsibility to have team members responsible for preparing some didactic presentations. ” What is good about this feedback? How could the feedback be improved?

Feedback Case 4 • “What a delight to work with Resident X as one of the two upper levels. She functioned as an excellent upper level. Her work ups were efficient and accurate and she knew when she wanted a consultant's opinion (and I would agree). She appropriately followed up tests and medicines, particularly prior to discharge to minimize problems/holes in follow up. She even picked up an unnoticed finding on a test that absolutely changed our disposition/management of an elderly woman with syncope, anemia, and severe carotid stenosis. I am thankful to work with a resident who is attentive to details. She kept up with discharge summaries in a timely way and they were helpful. My only advice is to consider the conversations at the bedside. My perception is that sometimes she felt hurried/nervous and sometimes the language was vague when the patients/family members wanted more specifics (like she was not wanting to discourage or deliver bad news or at least not in front of people). This may have been just my perception of things. Of course her bedside manner/care is wonderful. She is very caring about the patients. ” What is good about this feedback? How could the feedback be improved?

Feedback Case 5 • “Solid performance all around. ALWAYS prepared with his pts' info and data. Calm, low key professional demeanor. I would like to see Resident X more active verbally during our sit down rounds. His few questions were very insightful and I encouraged him to be more active in the verbal sparring that goes on during rounds. ” What is good about this feedback? How could the feedback be improved?

Feedback Case 6 • “Resident X did a good job on his inpatient rotation early in his internship year. He was able to blend learning a new EMR and order-entry system with learning about his patients. Resident X demonstrated compassion to his patients, clinical curiosity, and a willingness to expand his knowledge base and accept feedback. We discussed ways to better organize his progress notes and clinical presentations during rounds, both of which he demonstrated improvements in during the week we were together. Good performance for early in his internship!” What is good about this feedback? How could the feedback be improved?

Session Goals • Critique actual feedback • Examine the principles of effective feedback and evaluation • Review common traps and barriers in the evaluation & feedback process • Discuss feedback delivery models • Identify feedback common opportunities in family medicine education

Comments or Questions? Ann Hiott Barham John Turner abarham@wfubmc. edu jlturner@wfubmc. edu