Strategies for Effective Feedback in Medical Education PROFESSIONAL

Strategies for Effective Feedback in Medical Education PROFESSIONAL DEVELOPMENT Basics Program for New Faculty – Day 1: October 3, 2013 Presenters: Sarah Fleming MD CCFP, Gweneth Sampson MD CCFP FCFP MSc. CH Facilitators: Helen Batty, Allyson Merbaum, Sarah Reid, Michael Roberts, Gweneth Sampson, Find this slide presentation at www. dfcmopen. com/item/effective-feedback-in meded Monica Sethi, Barbara Stubbs

This set of slides is adapted for DFCM Open. You can download these slides at www. dfcmopen. com/item/effective‐feedb ack-in-meded. Find a handy one-page reference about giving feedback at www. dfcmopen. com/item/giving-feedbackbasics. Find this slide presentation at www. dfcmopen. com/item/effective-feedback-inmeded

The objectives of the “one-pager”, which includes a list of references, are as follows: 1. Describe the role, models and characteristics of constructive feedback in education. 2. Understand some of the common challenges and barriers to effective feedback, including the role of student self-assessment. Find this slide presentation at www. dfcmopen. com/item/effective-feedback-inmeded

LEARNING OBJECTIVES • Participants will be able to: – Describe the role, models, and characteristics of constructive feedback in education – Understand some of the common challenges and barriers to effective feedback, including the role of student self assessment – Demonstrate feedback techniques

OVERVIEW OF WORKSHOP • Background Information • DVD: Resident scenario • Feedback Role Play • Feedback Checklist • DVD: Small Group Exercise • Summary

KEY MESSAGES • Trainees state that feedback is the main item they don’t get enough of in teaching sessions (Hewson and Little, 1998) • The process of giving feedback is as important and structured as taking a good history • Focusing on attaining a comprehensive student selfassessment and establishing a dialogue are keys to good feedback (Ende, 1983; Ramani & Krackov, 2012) • We need to give better feedback - not necessarily more

FEEDBACK: DEFINITIONS • Feedback is the sharing of information on actual performance to help guide the student’s future performance toward a desired goal (Ramaprasad, 1983) • It is essential to learning • It requires a sample behaviour, a clear model of the desired behaviour, and a demonstration of the difference between the two

TYPES OF FEEDBACK Formative • Aimed at improvement • Gathered to inform change Summative • After-the fact • Evaluation • Judgment • Eg. Field Notes • Eg. End of Rotation Evaluations (ITERS) Feedback is most useful when provided during a formative evaluation (Sadler, 1989)

WHY GIVE FEEDBACK? “Feedback can change physicians’ clinical performance when provided systematically over time by an authoritative credible source” (Velosky et al. , 2006)

FEEDBACK MODELS • Sandwich Technique “positive/negative/positive” • Pendleton Method (Cantillon and Sargeant, 2008) • Relative Ranking System • EFPO “ 6 Step” Model (Educating Future Physicians of Ontario)

EFPO MODEL OF FEEDBACK (SIX STEP) 1. Teacher observation of student behaviour or work 2. Ask the student for their self-assessment 3. Describe the desired behaviour 4. Ascertain that the student understands the difference between current behaviour and desired behaviour 5. Elaborate a plan to close the gap (an educational prescription) 6. Follow-up on improvement Merrilee Brown, Brian Hodges, J. Wakefield, Effective Feedback, 1995

AN EXAMPLE - PARALLEL PARKING 1. Observe student parallel parking (too far from the curb) 2. Ask for self assessment - “How do you think that went? ” “What did you do well? ”… “Is there anything that didn’t go as well as you had hoped? ” 3. Describe desired behaviour - “You did a great job at checking the space around the car. Next time I would recommend parking closer to the curb… Indeed, this can be tricky sometimes” 4. Check if student understands the difference between current parking and desired parking – “What do you think about my suggestion of parking closer to the curb? ” “How much closer would you like to be next time? ”…“Yes, two feet closer sounds good”

AN EXAMPLE - PARALLEL PARKING 5. Make a Plan to close the gap - “Is there anything that you can think of that may improve it for next time? ” … “ I agree, and you could also try slowing down the car as you reverse. Why don’t you watch me park, then practice this again for 10 minutes every day” 6. Follow-up on improvement - “I will observe you park again in 3 days and we can touch base to see how things are going”

CHARACTERISTICS OF EFFECTIVE FEEDBACK Solicited Descriptive Limited – 1 or 2 points Well-timed Focus on modifiable behaviours Dialogue Specific Create a supportive environment Balanced Authentic Verifiable Provided regularly over time

CHARACTERISTICS OF EFFECTIVE FEEDBACK: CORBS Characteristics of Effective Feedback: • • • Clear Observed (and Owned) Regular / Restricted Balanced Specific

POSSIBLE BARRIERS TO THE PROVISION OF EFFECTIVE FEEDBACK • Little or no instruction on how to give feedback • Fear of damaging relationship with learners • Hierarchy issues between teacher and learner • Cultural context issues • Students’ ability to self-assess

SELF-ASSESSMENT OF COMPETENCE: WHY IS IT AN IMPORTANT SKILL? • Leads to increased motivation and improved knowledge, communication and performance (Evans, 2002) • The ability to accurately assess one’s own strengths and weaknesses is the first step in self-directed learning (Boud, 1990) • Physicians are responsible for their own continuing medical education

SELF-ASSESSMENT OF COMPETENCE: Are we good at self-assessment?

SELF-ASSESSMENT OF COMPETENCE: Self assessment high Risk group (Dunning and Kruger, 1999) Risk group Burnout potential Vicious cycle of incompetence Competence low average high

SELF-ASSESSMENT OF COMPETENCE: Can we improve our self-assessment skills?

SELF-ASSESSMENT OF COMPETENCE: (Dunning and Kruger, 1999) Self assessment high Risk group Improved competence creates improved self assessment skills Risk group Burnout potential Competence low - insight - ability to use feedback average high

SELF-ASSESSMENT OF COMPETENCE: Self assessment high (Dunning and Kruger, 1999) Improvement in self assessment after viewing “benchmark” videos (Martin et al. , 2004) low average high Competence

FEEDBACK AND REFLECTION • Feedback self-assessment reflection • Although self-assessment is often inaccurate, self assessment skills can be learned • Reflection and self-assessment are critical for lifelong learning • Reflection accelerates learning and improves the depth of understanding (Westberg & Jason, 2001) • Reflective practioners are likely to provide better patient care

USEFUL RULES FOR ROLE-PLAY AND DEBRIEFING • Preferable to recruit volunteers, not assign roles • Refusal always allowed • Time out whenever needed “T” • Role players debrief first – most anxiety provoking roles first (no interrupting) – may be given a reasonable time limit in advance • Role players discuss first – with each other – ask observers questions for specific feedback and advise them of areas “off limits” for comment • Observers provide specific careful feedback following guidelines – use data from field notes “quotations” etc. – respect requests and limitations set by role players • Time keeper keeps track of start and stop times Batty’s Rule: 1 minute of role playing 2 to 10 minutes of debriefing

LARGE GROUP DEBRIEF • What strategies worked? • What was a challenge? • What will you try in future?

WRAP-UP - REVIEW OF OUR LEARNING OBJECTIVES • Participants will be able to: – Describe the role, models, and characteristics of constructive feedback – Understand some of the common challenges – Demonstrate feedback techniques How Did We Do?

PRACTICAL TIPS • • • Label this as “Feedback” Think about Timing and Privacy Link to Learner’s Objectives Provide Opportunity for Change Get Feedback on your Feedback Follow-Up

KEY MESSAGES • Feedback is crucial to the improvement of performance, self assessment skills and reflective practice • Process = 6 step EFPO model: observe, student selfassessment, describe behaviour, describe the gap, make an educational plan and follow up • CORBS: Clear, Observed, Regular, Balanced, Specific • Just do it (and label it!)

REFERENCES • • Branch W and Paranjape A (2002). Feedback and Reflection: Teaching Methods for Clinical Settings. Academic Medicine 77 (12): 1185 -1188 Cantillon P and Sargeant J (2008). Giving feedback in clinical settings. BMJ 337: a 1961. Davis D, Mazmanian P, Fordis M, Van Harrison R, Thorpe K, Perrier L (2006). Accuracy of Physician self-assessment compared with observed measure. JAMA 296(9): 1094 -110 Dunning D, Kruger, J (1999). Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments. Journal of Personality and Social Psychology 77 (6): 1121 -34. Eva K and Regehr G (2013). Effective feedback for maintenance of competence: from data delivery to trusting dialogues. CMAJ April 2; 185: 463 -464 Evans A, Mc. Kenna C, Oliver M. (2002). Self-assessment in medical practice. J R Soc Med 95: 511 -513. Hewson MG, Little ML. (1998). Giving feedback in medical education: Verification of recommended techniques. J Gen Intern Med 113: 111– 118.

REFERENCES • Mann K, Gordon J, Macleod A. (2007) Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Edic Theory Pract 2007; 14: 595 -621. • Martin D, Regehr G, Hodges B, Mc. Naughton N. (1998) Using videotaped benchmarks to improve the self-assessment ability of family practice residents. Acad Med. Nov 73(11): 1201 -6. • Ramani S, Krackov S. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher 34: 787 -791. • Ramaprasad A (1983) On the definition of feedback. Behav Sci 28: 4 -13. • Sadler, DR (1989) Formative assessment and the design of instructional systems. Instructional Science 18: 119 -144. • Sandars J. (2009). The use of reflection in medical education: AMEE guide 44. Med Teach 31: 685 -95. • Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. (2006). Systematic review of the literature on assessment, feedback and physicians' clinical performance: BEME Guide No. 7. Med Teach. Mar; 28(2): 117 -28. • Westberg, Jane & Jason, Hilliard. (2001) Fostering Reflection and Providing Feedback, New York: Springer Publishing Co.

Thank You! Find this slide presentation at www. dfcmopen. com/item/effective-feedback-inmeded