Feedback in Clinical Teaching Susan T. Hingle, M.D., F.A.C.P. Internal Medicine Clerkship Director Associate Residency Program Director Associate Doctoring Curriculum Director

AMC Grand Rounds Clinical Competency Feedback AMC Grand Rounds Clinical Competency Feedback

Feedback 1. DO IT! 2. BE NICE! 3. BE HONEST! Regina Kovach, M.D.

Feedback “A constructive, non-evaluative, objective appraisal of performance intended to improve the learner’s clinical skills.”“A constructive, non-evaluative, objective appraisal of performance intended to improve the learner’s clinical skills.” Mariana Hewson, PhD

Feedback “Information that a system uses to make adjustments in reaching a goal… Feedback occurs when a learner is offered insight into what he/she actually did as well as the consequences of his/her actions.”“Information that a system uses to make adjustments in reaching a goal… Feedback occurs when a learner is offered insight into what he/she actually did as well as the consequences of his/her actions.” Jack Ende (1983)Jack Ende (1983)

Feedback One of the most powerful ways for a teacher to motivate the learnerOne of the most powerful ways for a teacher to motivate the learner Enhances the learner’s strengthsEnhances the learner’s strengths Improves the learner’s weaknessesImproves the learner’s weaknesses Essential responsibility to learners, their patients, and the educational programsEssential responsibility to learners, their patients, and the educational programs

“Feedback is a Way to Ensure That Learners Stay On Course” This is rocket science!This is rocket science! The concept of feedback goes back to the 1940’s and rocket engineers: when a rocket was launched into space, a radio transmitter sent signals back to earth to track it so adjustments could be made if it veered off course.The concept of feedback goes back to the 1940’s and rocket engineers: when a rocket was launched into space, a radio transmitter sent signals back to earth to track it so adjustments could be made if it veered off course. Jack Ende, M.D

Feedback and Evaluation FeedbackFeedback Goal based and objectiveGoal based and objective CoachingCoaching FormativeFormative TimelyTimely Professional developmentProfessional development Evaluation Goal based and objective Judging Summative After the fact Quality Assurance

Feedback = Coach Timely, immediate, ongoingTimely, immediate, ongoing DirectDirect VerbalVerbal Guiding future performanceGuiding future performance Face to faceFace to face

Evaluation = Judge SummativeSummative Not ongoing, occurs at the end of time togetherNot ongoing, occurs at the end of time together Assesses whether or not learner met performance standardsAssesses whether or not learner met performance standards

Types of Feedback Reinforcing (aka positive)Reinforcing (aka positive) Corrective (aka negative)Corrective (aka negative) SummativeSummative –Cumulative, additive –Assessed work which contributes to the final outcome of a student’s grade FormativeFormative –Shaping, moulding, constructive

Who Should Give Feedback? Anyone responsible for trainee’s evaluationAnyone responsible for trainee’s evaluation Anyone who directly observes the learnerAnyone who directly observes the learner Anyone with experience and knowledgeAnyone with experience and knowledge EXAMPLES: learner to learner, staff to learner, learner to preceptorEXAMPLES: learner to learner, staff to learner, learner to preceptor

Impediments to Quality Feedback Unclear goals and objectivesUnclear goals and objectives Lack of direct observationLack of direct observation Failure to set a good learning climateFailure to set a good learning climate Lack of teacher trainingLack of teacher training Teacher’s insecurity and anxietyTeacher’s insecurity and anxiety Lack of timeLack of time Learner and teacher may have different perceptions of performanceLearner and teacher may have different perceptions of performance

Giving Feedback: Do’s DO set expectationsDO set expectations DO let the learner go firstDO let the learner go first DO use language that is specific, descriptive and non-evaluativeDO use language that is specific, descriptive and non-evaluative DO use “I” when giving subjective feedbackDO use “I” when giving subjective feedback DO focus and regulate quantity of feedback so it’s not overwhelmingDO focus and regulate quantity of feedback so it’s not overwhelming

Giving Feedback: Do’s DO consider giving feedback in a sandwich formatDO consider giving feedback in a sandwich format DO base feedback on direct observationDO base feedback on direct observation DO be concerned with decisions and actions (not intentions)DO be concerned with decisions and actions (not intentions) DO be timely with feedbackDO be timely with feedback

Giving Feedback: Don’ts DON’T focus on the learner but on the learner’s actionDON’T focus on the learner but on the learner’s action DON’T give feedback at bad timesDON’T give feedback at bad times DON’T press if the learner seems threatenedDON’T press if the learner seems threatened DON’T give futile feedbackDON’T give futile feedback

Methods RRRCRRRC –Reflection –Rules –Reinforcement –Correction CEDARCEDAR –Clarify –Explain –Discuss –Agree –Review

Key Principles to Remember Plan for feedback from the startPlan for feedback from the start Be behavior specificBe behavior specific Be timelyBe timely Be brief and conciseBe brief and concise Be balancedBe balanced Respect privacyRespect privacy Always ask for reciprocal feedbackAlways ask for reciprocal feedback Involve others when appropriateInvolve others when appropriate Victoria Kaprielian, M.D. Margaret Gradison, M.D.

How Are We Doing? SIU RESIDENCY END OF YEAR EVALUATION (N=158, 72% Response Rate) SIU RESIDENCY END OF YEAR EVALUATION (N=158, 72% Response Rate) No Response PoorFairGoodExcellent Provision of feedback by full-time faculty Provision of feedback by community faculty

Setting Expectations Videoclip 1Videoclip 1Videoclip 1Videoclip 1 Videoclip 2Videoclip 2Videoclip 2Videoclip 2

Student Presentations Videoclip 1Videoclip 1Videoclip 1Videoclip 1 Videoclip 2Videoclip 2Videoclip 2Videoclip 2

Interpersonal Skills Feedback Videoclip 1Videoclip 1Videoclip 1Videoclip 1 Videoclip 2Videoclip 2Videoclip 2Videoclip 2

Feedback: One Minute Preceptor Example VideoclipVideoclipVideoclip

Practice Vaccination videoclipVaccination videoclipVaccination videoclipVaccination videoclip Patient comfort videoclipPatient comfort videoclipPatient comfort videoclipPatient comfort videoclip

Feedback: Conclusions Feedback is a critical part of learningFeedback is a critical part of learning Giving feedback is a skill that doesn’t come easily and must be practicedGiving feedback is a skill that doesn’t come easily and must be practiced Less is moreLess is more –focus –provide often but in small amounts

Feedback DO IT!DO IT! BE NICE!BE NICE! BE HONEST!BE HONEST! Regina Kovach, M.D.