New Directions in the Practice of Giving Feedback David Hatem MD Mark Quirk EdD Sophie Davis School of Biomedical Education Faculty Development Workshop November 17, 2008

New Directions in Feedback: Focus on Feedback Links to Articles Slides

Objectives  Review Feedback  Discuss ways to bring feedback to a higher level by focusing on clinical expertise  Insure continuity of learning through feedback and action plans

Introduction: The Stepping Stones Exercise  Introduce yourself to group members by: Picking 3-5 significant events or people who are important in getting you to where you are today (your “stepping stones”) List them in chronological order Tell the members of your small group about your stepping stones

Debriefing the Stepping Stones  What effect does this exercise have on the formation of your group?  What effect, if any, will it have on explaining and allowing different perspectives to be heard in the group?  What effect will it have on feedback?

Following up on the Spirit of Stepping Stones: Checking In  What is it like to be in this group today, right now?  Ask students to briefly report or “check in” about anything that has happened since the last meeting that they think is affecting their presence in the group today  Often hear about Good news Personal or professional challenges Simple readiness to learn

The Goals of Feedback Ensuring that the learner improves, while at the same time maintaining his/her self-respect.

Effective Feedback  Encourages self-assessment  Covers positives and negatives  Refers to specific, observed behavior  Limited in the amount  Timely  Occurs in an appropriate place  Ends with an action plan

The Language of Feedback  Call it feedback  Is attentive to the power differential  Is non-judgmental (“I” statements v “you” statements)  Label the subjective (“I wonder if…” “My impression was…”)  Assesses reaction to feedback

Elevating Feedback to a Higher Level Fostering the Development of Clinical Expertise

Objectives  Define ‘high level skills’ that constitute clinical expertise  Use questioning to ‘deliver’ feedback around these skills  Negotiate an action plan to conclude the delivery of feedback and propel learning

What are the high level skills of clinical expertise?

Thinking about one’s own or another’s thinking or feeling

Anticipates patient’s reactions (and plans accordingly) Reflects on potential bias that could impede problem-solving Reads patient’s clues and adapts Recognizes and regulates own tendencies (e.g., to control the interview) Understands the patient’s concern and perspective Effective Clinical Communication and Problem-solving: A Metacognative Approach

Why Focus on These Skills?

1.Didn’t know enough about the disease 2.Didn’t Reflect on Potential Biases Bordage, 1999 Residents: Why did you miss dx past year? Was influenced by a ‘similar’ case Was in denial of an ‘upsetting’ dx Was in too much of a hurry Let the consultant convince me Didn’t reassess the situation Pt had too many problems at once

Reflection as a ‘Debiasing’ Strategy Croskerry, Acad. Med  “A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics and biases.” (Cognitive Dispositions to Respond -- CDRs)  Metacognition is an effective strategy -- “stepping back from the immediate problem to reflect on the thinking process

(Four of 30) CDRs should be an Essential Part of Teaching Problem-solving (Four of 30)  Posterior probability -- estimate of likelihood is unduly influenced by what has gone on before in physician’s and or patient’s past  Omission bias -- rooted in the ethical principle ‘Do No Harm.’ Events that occur in natural progression of a disease are more acceptable than those that result from physician intervention  Sutton’s slip -- dx possibilities other than the obvious are not given enough consideration  Anchoring -- tendency to ‘lock on’ to salient features in the initial presentation and failing to adjust

Acute Left Shoulder Pain 1. Previous patient with MS was in acute crisis and had to be sent to the ER 2. This patient with shoulder pain was lifting a motorcycle engine into place four days ago when pain developed 3. Doctor on call recommended Advil 4. Pain persisted 5. At this visit - Shoulder and cardiac exam normal - ECG - normal - Didn’t admit to ER despite the severe pain 6. Next day the patient died en route to the ER 7. Reflection: I could have logically sent him to the ER but: - Two patients in a row to the ER? Never happened before - Didn’t believe this was his heart based on what I knew about him (young, strong, alcoholic) and test results - Also knew he would argue with me about going to the ER because that’s the type of patient he was

Listening for Clues into the Patient’s Perspective*  Clues per visit  Emotional in nature  Responded positively to patient emotions Levinson, et al 2000 JAMA Surgeons Primary Care %70% 38%21% * Visits with missed opportunities tended to be longer

Missed Clues (Empathic Opportunities)  Thoracic surgeons or oncologists responded to 39/384 empathic opportunities (10%)  5 0 % o f t he s e statements occurred in the last one-third of the encounter, whereas patients concerns were evenly raised throughout the encounter.  Conclusion: Too little too late Morse, et al 2008

The Literature on Self-Assessment in Medicine  Students underestimate their performance in 1st two years (on exams) and overestimate performance in 3rd year (on OSCEs) (Fitzgerald, White & Gruppen, Med. Educ., 2003)  Students in the 3rd year of a PBL curriculum who completed self- assessments before and after an oral exam demonstrated poor accuracy when compared with actual performance (Tousignant & DesMarchais, Adv in Health Sci Educ, 2002)  No relationship between self and instructor assessments in all competency areas for PGY1s (Barnsley, et.al. Med.Educ. 2004)  65% of studies that compare physicians’ self assessment with external observations (gold standard) of their performance show little, no or an inverse relationship (JAMA, 2007)

‘My Test Results’ Medical Student who Excels at Following Protocol

How do we ‘deliver’ feedback around these high level skills? Focus on Thinking Skills Encourage reflection Engage in perspective-taking Facilitate self-assessment Focus on Action Plan Goal setting Monitoring Use Questions to - -

Types of Questions Asks focused questions Asks leading questions Uses open/ exploratory questions Uses open/ Reflective questions Teacher Learner KnowledgeMetacognition

Integrating opinion, direction, information and questioning to deliver feedback The Sexual History

Role of the Teacher anticipate and reflect gain insight about self and others’ perspectives learn how to learn (lifelong) improve clinical performance Use effective feedback to help the learner

Teaching Role-Play ‘My Test results’

Case Discussion and Practice

1.Goal: Identify a learning goal and get agreement. 2.Need: Consider what the student says he/she needs. 3.Objectives: Make them explicit. 4.Methods: Encourage the student to offer ideas that match learning style and resources. 5.Re-Evaluate: Set a time to re-evaluate. * Develop an Action Plan for a role-play case Action Plan*

To improve performance by using explicitly stated objectives and strategies.To improve performance by using explicitly stated objectives and strategies. To teach skills that encourage self assessment and self correction (independence and life long learning).To teach skills that encourage self assessment and self correction (independence and life long learning). Reason for Action Plan

The Action Plan:Prioritizing and Insuring continuity  How do you assure student continuity from one interview to the next when time has elapsed?  How do you build on skills?  How do you remember what they were working on?  How do they?

The Action Plan:Prioritizing and Insuring continuity  Do the interviews sequentially build skills? Progressively more complex Similar or different tasks How does one set of interviews inform others in the curriculum? What are you building toward? Complete history A Tool box of skills

Case Discussion