Making a Better Sandwich

Giving Effective Feedback Handout: Making a Better Sandwich

Take Home Points

• Feedback is essential • Feedback is desired by learners • Effective feedback requires preparation • Give SOME-TLC via Ask-Tell-Ask-Act

Activity #1 – Feedback Reflection – 2 minutes

Write down 1-2 words that come to mind when you think of feedback. Share these with the others at your table.

Be prepared to discuss any common themes that are present.  Word #1

 Word #2

 Common Themes:

Activity #2 – Feedback in Literature – 8 minutes

Highlight concepts of effective feedback that are important to you.

Be prepared to discuss with the group.

Giving Effective Feedback by W. Fred Miser, M.D.

The feedback we give to students should be for one primary purpose - to keep them on course so they arrive successfully at their predetermined destination (the attainment of the skills, attitudes and behaviors that will make them outstanding physicians).

Feedback is not "rocket science." It is an objective description of a student’s performance intended to guide future performance. Unlike evaluation, which judges performance, feedback is the process of helping our students assess their performance, identify areas where they are right on target and provide them with tips on what they can do in the future to improve in areas that need correcting. Students will invariably say they do not receive enough feedback from us as teachers. Think about your own training. Did your teachers let you know what you were doing right, and what areas needed improvement? Did you receive enough feedback? Chances are your teachers let you know when you strayed off course, but did they focus on what could be done in the future so that you would not repeat the error? To be effective, feedback should consist of these characteristics:

1. Good feedback should be timely. The best feedback occurs on a daily basis, not just at the end of the rotation. If done frequently, our comments will seem less like an evaluation, and more like helpful suggestions. Take time after an encounter or procedure to provide feedback to the students.

2. Feedback is meant to be constructive. It is intended to improve future performance, and should be given for no other reason. It is not meant to demean or punish the student. Describe your observations and your own reactions.

3. The best feedback is specific. Use precise language about what specifically they did right or what they need to do to improve. Students may momentarily feel good about themselves when you say, "You did a good job." However, they will also wonder what specifically they did that earned your praise. Instead of saying, "You are clumsy," provide specific feedback such as, "The patient appeared uncomfortable when you were using the otoscope."

4. Feedback is focused on behavior, preferably ones that can be repeated, and not on the individual. Focusing on the behavior allows a dispassionate dialogue with the student.

5. Good feedback should be based on personal observations, not on hearsay.

6. Feedback should be verified. Make sure the student understood your feedback, and then follow up with a plan to monitor and assist the student in those areas that need correcting.

There is an art to giving feedback. If not done properly, or done with the wrong intention, the student will take your comments as criticism. At the beginning of the rotation ask the students how often they would like feedback, and develop a plan on providing that feedback to them. Then, before you provide feedback, take a few moments to choose the words you will use, and confirm your motivation that you are providing that feedback to improve their performance. Avoid evaluative language; its use can cause the student to respond defensively.

Feedback should be done as soon as possible, unless emotions will interfere with the session. Excellent feedback given at an inappropriate time may do more harm than good. Often after a bad outcome, students are working through their own emotions, and are often quite critical of their performance. At this time, brief feedback and emotional support are best, followed later by a more detailed feedback session. Feedback should also be done in private, unless it can be given in such a manner as to not be embarrassing. An old axiom is to "praise in public" and "critique in private."

It is often helpful to ask the students to assess their own performance. Often they will be more harsh about their performance, which then allows you to be more positive in your approach. It is much easier and more effective for you if the students identify areas for improvement; you can then help them develop a plan of action as to how they can do things differently in the future. When assessing performance, focus on what went well, and what can be improved. Gain consensus with the students; feedback is more effective if you and the students agree on this assessment. Some educators advocate the P-N-P (positive-negative-positive) sandwich approach to providing feedback. Begin with a positive statement, then give corrective feedback and conclude with another positive assessment. However, the positive comments must be genuine, or you will lose credibility with the student. Remember to focus on the performance and behavior, not on the person. Also, focus on those behaviors that the student can do something about. Reminders about shortcomings over which the student has no control only leads to frustration.

When determining a plan of action for improvement, ask the students what they can do. Again, gain consensus with the students; future performance is more likely to improve if they agree with the plan. It is helpful to set goals for future performance. "Next time you encounter this, try this...," then verify that the students understand, and if the opportunity arises, confirm that they did change their behavior.

In conclusion, Jack Ende has written, "The goal of clinical training is expertise in the care of patients. Without feedback, mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved empirically or not at all." (Ende J: Feedback in clinical medical education. JAMA 250(6):777-81, 1983).

We should provide feedback often to our students, helping them to stay on track so they can achieve their ultimate goal of being outstanding physicians. It is a skill that can be developed, and I encourage you to keep this foremost in your mind as you work with the students in your office.

Activity #3 – Feedback versus Evaluation– 3 minutes

Using an arrow, place the descriptive words under the appropriate heading. Some words may fall under both headings.

FEEDBACK EVALUATION

Objective Immediate Scheduled Informal Formal Observational Dialogue Monologue Grading Improving Event Specific Global Performance Activity #4 – Cases – 3 minutes

In groups of 2, each person pick one scenario that you will later (activity #5) give feedback for. Highlight items from your scenario that you would use to provide feedback keeping in mind SOME-TLC.

Case #1: (Medical resident scenario) You observe a resident performing a colposcopic exam, and biopsies. The resident was excellent in the explanation and consent of the procedure to the patient. The patient jumps slightly during the placement of the speculum and states, “that’s uncomfortable!” The resident repositions the speculum slightly and states “ Sometimes it is going to hurt a little”. The resident follows the appropriate sequence of actions, identifying an appropriate area to biopsy. As the resident continues with the procedure, the patient intermittently makes sounds of slight discomfort when the speculum is bumped and particularly with the biopsy. When the resident has completed the procedure, the patient asks if she can have any medication for pain. The resident replies stating, “colposcopy is not that painful, and you should be fine with over-the-counter Motrin. Even that is not needed for most people.” The resident concludes by stating he will call the patient with results, and he feels confident that she has only minor changes, that may not require further intervention.

Case #2: (Non medical scenario) You are teaching a class via a series of interactive workshops. Most but not all students are there as an elective course. The curriculum requires reading between sessions. All sessions require active participation One of your students, Mary, started the course strong and you though she was going to be one of the top students. Recently, you note that a Mary is frequently 4-5 min late for each session. She often seems to be poorly organized upon arrival. She is somewhat reluctant to be involved. Today during a group session she was texting on her phone. Another student asked her to participate or leave. She set the phone down, and returned to the activity. When she does participate she gives insightful answers to the group. She is good at following specific directions when engaged. However this does not occur every session. You overhear a student stating, “Mary is either completely unaware that she is a drag on our group, or she just doesn’t care.

Activity #5 – Giving Feedback – 10 minutes

Using the items you highlighted above, each person practice giving effective feedback using the Ask--Tell/Teach--Ask--Act model for your case. Your partner will play the learner who will receive the feedback. To facilate dialogue, the learner (partner receiving feedback) should incorporate the following relevent information below about their case into the feedback sesson. The person giving feedback for the case should avoid reading the learner’s additional information.

Be prepared to discuss with the group how your interaction went. Activity #6 – Commitment to Improving Feedback – 5 minutes

Using what you have learned today and feedback needs of our students, list what you will do in the next month to improve feedback to your learners.

Be prepared to share.