II Delivering effective feedback 1 04 7 27

II. Delivering effective feedback 醫學教育部 林季緯主任 1 04. 7. 27

Feedback vs. Evaluation • Feedback: • 持續提供（on-going provision）學員表現狀況的訊息，以導引並 改善（guide and improve）未來的努力方向 • Evaluation: • 對於先前表現的評判（judgment）

Everyone Seeks Feedback… • And if we don’t get it, we make assumptions and attributions! • Self-assessment is notoriously unreliable • 沒有即時有效的回饋，學員可能會錯誤地減少某些被期待的行為 （extinguish desirable behaviors） ，反而保留了一些不受歡迎也不 恰當的行為（entrench undesirable ones） • Medical teachers don’t deliver as much feedback as they think…

Are International Medical Students • YES • And NO Different ?

How IMGs May Be Different… • 巨大的文化差異 Tremendous cultural diversity • 老師的小批評可能被學生解讀為犯了嚴重錯誤 Critique may be viewed as serious error • 師生權力關係的解讀可能有差異 Power dynamics may be different • 不願意暴露弱點 Difficulty in exposing weakness • 失敗的後果 Consequences of failure • 年紀較大 Older than other learners • 家庭環境與經濟壓力 Family circumstances and financial burdens • 對新文化與新環境的適應調整 Adjustment to new culture and language

Commonly Reported Issues • Medical knowledge • Clinical skills • Communication skills • Language skills • But these are HIGHLY variable between individuals!

Think of Times When You, as a Learner, Have Received Feedback… • When it was helpful – what was it that made it so? • When it was not useful – why was that?

Steps in Delivering Feedback Build an environment of trust and support • 以身作則，尋求回饋或給予回饋 (asking for, and using, feedback) • 以身作則，展現對知識技能不足的包容性 (an acceptance of personal gaps in knowledge and skill) • 傳達有的時候犯錯是無可避免(mistakes are inevitable)的認知 • 主動鼓勵學員尋求建議或協助

Steps in Delivering Feedback Plan ahead and negotiate • 回饋不應該僅是意外的驚喜（come as a surprise） • 澄清回饋feedback (coaching)和評估evaluation (judgment)的不同 • 尋求更多觀察的機會（opportunities to observe）

Steps in Delivering Feedback Choose appropriate timing and setting • 越及時越好 （As close in time as possible） • 及時的回饋（quickie feedback） ，如有必要再加上稍後詳細的討 論（later discussion if necessary） • 注意隱私 • 要關注學員情緒

Steps in Delivering Feedback Focus on the positive, not just the negative • 老師常會為了快速矯正錯誤（quicker to correct）而忽略鼓勵正向 行為（reinforce） • 引發正面的情緒（positive feelings）有助於學員樂意進行改變 • 用正面的詞彙positive terms框架住有用的訊息 • 指出其行為帶來的影響（impact of behavior）

Steps in Delivering Feedback Use a feedback model (sandwich or grid) • 系統化的方式（systematic approaches）是有用的 • 三明治法（PNP sandwich） • highlight a positive aspect, then one to be improved, then another positive • 回饋方格Feedback grid • adapted from the Bayer Institute • behaviors to continue, or do more of; behaviors to start doing; behavior to stop or do less of; future behaviors

Compliment Criticism Compliment

Feedback Grid Continue… Start, or do more… 對有用的行為表現加以回饋，要專 一，且描述其影響性，強調有哪些 事是以後我們還期待看到的。 找出那些學員知道、應該要做， 或者是應該要多做一些的行為。 Comment on aspects of performance that were effective. Be specific and describe impact. Highlight things you would like to see done in the future. Consider… Identify behavior the student knows how to do and should do, or do more often. Stop, or do less… 強調一個可協助學員成長的重點， 指出有哪些行為是無用甚至是有 一個學員在未來可以做得到的挑戰。 傷害性的，要有專一性，且指出 Highlight a point of growth for the student, a 其潛在影響。 “doable” challenge for future interactions. Point out actions that were not helpful, or could be harmful. Be specific and indicate potential impact.

Steps in Delivering Feedback Include follow-up plans • 新的行為需要反覆加強（reinforcement） • 落實執行絕非易事 • 有策略地付諸實現 （putting it into practice） • 適時追蹤有助於加強改變成效 （reinforce change） • 並且要凸顯其成功的改變（highlights successes）

擬定改善計畫＆輔導追蹤的影響 • Creation of an action plan leads to change • Answers the “Where to next? ” question • Feedback alone does not cause change, it is the goals that people set in response to feedback (Locke et al, 1990) • Mentoring increases the likelihood of change following feedback

回饋方式 Accurate, specific, concrete v. s. Vague, generalized, impression 回饋的面向 認知面向 Cognitive domain: knowledge gap 情感面向 Affective domain: attitude issues 技能面向 Psychomotor skills

In Summary… • 建立互信的環境 Build an environment of trust • 事前規劃有效溝通 Plan ahead and negotiate • 引導自我評估 Elicit self-assessment • 決定適當的時間地點 Determine appropriate setting and timing • 強調正向行為 Focus on the positive • 選擇具專一性且可被改變的行為 Select specific changeable behaviors • 使用有效的回饋模式 Use a feedback model • 包括追蹤計畫 Include follow-up plans

Observing Learners. . What Are Your Opportunities and Strategies? In the same room: • Keep quiet • Avoid eye contact with the patient • Turn to the learner if addressed by the patient Use natural opportunities: • Listen to phone conversations • Hallway discussions Briefly observe many different parts of encounters

Practice Makes Perfect!