Giving Effective Feedback By Dr. SHILPA JAIN

Objectives At the end of this session the learner will be able to define/describe-  Feedback  Rationale for giving feedback in medical education  Common barriers to giving feedback  Types of feedback  Characteristics of effective feedback  Develop an action plan for improving feedback in their own practice

Feedback  Communication to another person which gives information about how he/she affects and is perceived by others.  A way of helping another person consider changing his/her behavior.

Feedback  An objective description of a student’s performance intended to guide future performance.  A 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.

The Student’s Needs  An understanding of what is to be learned  A communication to the task  Opportunities to practice  Opportunities to “process”  Constructive feedback

Rationale for Giving Feedback in Medical Education 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 1983;250:

Why Provide Feedback?  Improves performance  Reinforces positive behaviors  Corrects undesirable behaviors  Decrease learner anxiety about performance  Without feedback, formal tests become overly important  Improves self-assessment

Why Provide Feedback?  Essential for learning to take place  Our responsibility  Valued by students  Key step to ensure due process  So that evaluation is not a surprise!  Can enhance the teacher learner relationship  High skates outcomes

Barriers It is uncomfortable  Avoid confrontation  Learner will not be receptive  No one ever gave me feedback  Not quite sure how to do it  I hated getting feedback

More Barriers  I’m not sure of the goals or the expected behavior  Not sure that the observed behavior is really a problem  It’s not my job  It’s not that important  There’s not enough time

Students’ Perceptions of Feedback  My teachers don’t provide feedback.  Nobody tells me how I’m doing.  The comment “Keep up the good work” does not help me.  I get more negative feedback than anything else.  The feedback I receive is often vague, inadequate, and non-specific.

How Do They Differ?  Minimal Feedback/Reinforcement  Evaluation  Feedback

1.Reinforcement/ Minimal Feedback  Statement expressing positive (or negative) reaction to a behavior which aims to increase (or decrease) the likelihood of that behavior happening again  “That was a great presentation”  “You need to work on your presentation skills”  Often mistaken for feedback  Timing is similar - immediate

2.Evaluation  Qualitative judgment which ranks a learner’s performance in comparison to other learners  Often the only measure of performance visible to the learner  Usually given after the performance is over

2.Evaluation  Provide judgment  Involves several methods  Evaluation (on a scale)  Delayed  “Summative”

3.Feedback  (Reinforcement or correction) + Explanation  Keeps you on course to meet goals  Allows you to adjust your course to meet goals  Given immediately after the performance or at some time soon after, when the learner still has time to demonstrate improvement

3.Feedback  Provides information  Based on observations  Descriptive  Immediate  “Formative”

Three types of feedback in medical education  Brief feedback minutes  On a clinical skill  Formal feedback minutes  On a presentation, involves a dialogue  Major feedback minutes  Scheduled mid-point through a learning experience Branch J, Paranjape A. Feedback and Reflection: Teaching Methods for Clinical Settings. Academic Medicine. 2002;77:

What are the Essential Components of Feedback?  What was done well  What could be done better  What could be done to improve next time

Characteristics of Effective Feedback  Well timed and expected  Based on first hand data  Regulated in quantity  Phrased in descriptive language, based on specific remediable behaviors  Should be undertaken with teacher and learner working as allies, with common goals Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:

Characteristics of Effective Feedback  Well timed and expected  Set aside time; inform learner when it will occur  Avoid stressful situations for either party  Base feedback on first-hand data  Use “I-messages” to convey ownership of info  Any important aspect of duties worth including  If subjective or second hand, say so

Characteristics of Effective Feedback  Focuses on behavior, not individual  Offer an informed, objective appraisal  Identify clinical skills or actions for improvement  “Remediable behaviors”  Positive when deserved; negative to help  Should encourage learner to do better  Negative not critical of individual’s self-worth

Communicating Observations  Never let good work go unnoticed  Avoid being judgmental  Be specific, objective and non-threatening  Be aware of your body language  Avoid sending someone else to do your job  Avoid using “good news/ bad news”  Do not use sarcasm, insults, or accusations

Delivering the Message  Be proactive  Observe with intention of giving feedback  Know the performance criteria (clerkship objectives)  Begin with learner’s own assessment  Use “reflective listening” to facilitate their conclusion  Allows you to assess if any insight present

Delivering the Message  Offer feedback using principles outlined  Provide time for mutual problem-solving  See if learner recognizes problem areas  Ask for solutions.  Be ready with your own  Summarize the important issues  Get a commitment to follow-up on progress

Communicating Feedback Effectively  Assertiveness is about standing up for yourself, but also about respecting the opinions and needs of others.  When we communicate assertively, we are clear about our opinions and wishes, but we are also open to others’.

Passive, Aggressive, Assertive Passive Passive/Aggressive Aggressive Assertive

The Old Feedback Sandwich Praise Criticism Praise Is it more palatable?

The New Feedback Sandwich* Ask Tell Ask

Ask  Ask learner to assess own performance first  What went well and what could have gone better?  What were their goals?  Have they ever seen a patient like this before?  Begins a conversation  Assesses learner’s level of insight  Useful for second-hand feedback

Tell  Tell what you observed: diagnosis and explanation  React to the learner’s observation o Feedback on self-assessment  Include both positive and corrective elements o “I observed….”  Give reasons in the context of well- defined shared goals

Ask (again)  Ask about recipients understanding and strategies for improvement  What could you do differently?  Give own suggestions  Perhaps even replay parts of the encounter: “show me”  Commit to monitoring improvement together

Checklist: The Feedback Dialogue  Ask learner to assess own performance first  What went well and what could have gone better?  Tell what you observed:diagnosis and explanation  React to the learner’s observation  Include both positive and constructive elements  Give reasons in the context of well-defined shared goals  Regulate quantity

Checklist: The Feedback Dialogue  Ask about recipients understanding and strategies for improvement  What could you do differently?  Give own suggestions  Perhaps even replay parts of the encounter - show me  Commit to monitoring improvement together

Limit the Quantity

Summary  Remember 6 characteristics of feedback  Focus on specifics  Non-judgmental  Timely  Objective  Limited  Expected  Ask – Tell – Ask  Ask learners how they think they did/are doing  Tell learners what you observed  Ask learners how you can help them improve

Criteria for Effective Feedback In general, feedback should be:  Specificnot General  ImmediatenotDelayed  BehavioralnotInferential  DescriptivenotEvaluative  More or lessnot Either – Or  Asked fornotPushed Upon

End with Ende “The important things to remember about feedback in medical education are that (1) It is necessary, (2) It is valuable, and (3) After a bit of practice and planning, it is not as difficult as one might think.” Jack Ende, MD Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:

To summarize  Student feedback is like a dancer’s mirror.  It improves one’s ability to see and improve one’s performance. Alexander Astin, 1993 Feedback should be given in a way that the receiver can hear it, understand it, and choose to use or not use it.

Research on Feedback Feedback Improves:  Interviewing skills – Stillman, 1976  History-taking skills – Maguire et al, 1978  Clinical reasoning – Wington et al, 1986  Physical examination skills – Scheidt et al, 1986

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