Enhancing Feedback During Clinical Teaching Susan Frankl, MD Center for Teaching, Learning and Assessment Harvard Medical School October 14, 2009

Goals Review the principles of effective feedback Review the principles of effective feedback Practice giving feedback in challenging situations Practice giving feedback in challenging situations Troubleshoot problems and share solutions Troubleshoot problems and share solutions

Giving Difficult Feedback

originated from 1940’s rocketry- process of by which numbers or data were fed back to a rocket in flight to make any needed adjustments to ensure that it would stay on target.

Congratulating is EASY!

In contrast, problems are…hard to talk about

First, Assess the learner!

How do we assess learners? Establish standards and guidelines Test knowledge Review practice Observe performance Self-assessment and reflection Gather impressions of staff, patients, nurses, colleagues

What are the principles of effective feedback?

General qualities of effective feedback Should encourage improvement (not remind us of failure) communicated in a way that enables the learner to use it to their advantage An active process in which both giver and recipient take part and can grow personally and professionally

Specific features of good feedback: Contractual Stems from a set of common goals previously agreed upon Involves a 2-way discussion Builds on trust

Timely Should be expected Timely Ask yourself: –Is this person able to receive feedback right now? –Is this the right place?

Focused Is specific and avoids generalities Uses first-hand, accurate data Limited to behaviors that are remediable Ask yourself: –Do I have the facts, the detail? –Can I be specific? –Is this something the learner can/should improve?

Appropriate Objective- based on agreed upon standards Uses non-evaluative language Deals with decisions and actions not assumed intentions or interpretations Avoids “mixed messages” (e.g. “you did a good job, but….”)

Constructive Is problem solving Serves the needs of the learner Points to directions for improvement Comes to closure and gives sense of future directions

Constructive Ask yourself: –Can I be sufficiently calm and objective? If not, why not? –Am I willing to stick around long enough to pick up the pieces if all does not go well?

What makes giving feedback so difficult?

Concerns about giving difficult feedback EmbarrassmentHumiliationAngerConflict

Frameworks for Feedback Be Kind! Keep it Simple Think out Loud Federman’s Triad

Complicating Features Consider the possibility of the 5 D’s DepressionDeprivationDistractionDrugs Disordered personality

How do you proceed with giving feedback?

Conducting the Meeting Begin by seeking to understand learner’s state of mind (willingness to hear feedback) Make a general introduction and then solicit the fellow’s overall thoughts –Does he/she think there is a problem? –If so, what is their assessment?

Meeting continued Describe problem in detail, actions and consequences Include specific examples if has occurred more than once Focus on the behavior not personality or motives State the facts in no uncertain terms Be open about your reasoning “From the facts I have related, I am coming to these conclusions. Am I wrong?”

Meeting continued Listen to the response Expect some discomfort, defensiveness or disagreement Let the fellow talk it out Let the fellow save face Do not argue Make an effort to be silent and non- verbally supportive

LISTEN

Understand the learner’s perspective –“The nurse and I experienced your tone of voice as disrespectful to the patient when you said... How do you see it?” Listening and Understanding ≠ agreeing If you disagree, reflect together on the dilemma and see if the learner can propose a resolution Listening is a KEY tool!

Meeting continued In conversation that follows give positive support Make an action plan. Do you need to meet again? Make arrangements now.

Role-play cases

Directions Pick one person to be the attending/preceptor. Pick one person to be the learner. Others will be active observers. Attending: Read the case. Formulate in your mind the learners strengths and weaknesses. Consider what is your goal in giving him/her feedback. Conduct the meeting.

Directions continued Learner: Read the case. Get in to role. Observers: Make note of: Did the preceptor assess the fellow’s receptiveness to receiving the feedback? Was the feedback focused? Appropriate? Constructive? Did the preceptor listen? Provide positive support? Did they make an action plan?

Directions continued Debrief: 1. How did it go for the preceptor? What went well? What was difficult? 2. How did the feedback feel to the learner? Was it respectful, helpful? Is there a clear action plan? 3. Observers, what strategies did the preceptor use? What was successful? What did not work well? How likely is the learner to improve? How might the feedback meeting be improved?

Lessons Learned

Challenges How to give helpful feedback to a very enthusiastic, hardworking learner who is underperforming How to give feedback to learners who become defensive or “tune out”. How to give feedback on professionalism, treating staff members poorly

Challenges How to go from generalities “you did great” to specifics, especially if feedback cannot timely. How to give feedback to colleagues, e.g. amongst peers in lab meetings Giving feedback as a new attending

Challenges How to deal with not seeing improvement after specific feedback is given, e.g. going over notes and not seeing them get better in subsequent weeks How to provide feedback in a comfortable and confidential way when patient care issues interrupt or take priority (e.g. in the OR or clinic) How to provide feedback that promotes the learner to enhance their own style as opposed to adopting yours

Key feedback strategies Establish expectations early Timing is everything Praise in public; criticize in private Emphasize and repeat important points Be specific, focus on behaviors Respect the learner, consider his/her perspective Take the learner to the “next step” Make deposits in the “feedback bank” Good technique can be learned Practice, practice, practice

Acknowledgments Dave Roberts, M.D. BIDMC Sean Kelly, M.D. BIDMC Toni Peters, PhD. HMS Don Levy, M.D. HMS Gary Ferenchick, M.D. Michigan State University Society of Teachers of Family Medicine Preceptor Education Project

Contact Susan Frankl, M.D. Assistant Professor of Medicine, HMS Faculty Consultant, Center for Teaching, Learning and Assessment, HMS Primary Care internist, BIDMC Office: