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

Enhancing Feedback During Enhancing Feedback During Clinical TeachingClinical Teaching

Susan Frankl, MDSusan Frankl, MDCenter for Teaching, Learning and AssessmentCenter for Teaching, Learning and Assessment

Harvard Medical SchoolHarvard Medical SchoolOctober 14, 2009October 14, 2009

GoalsGoals

Review the principles of effective Review the principles of effective feedbackfeedback

Practice giving feedback in Practice giving feedback in challenging situationschallenging situations

Troubleshoot problems and share Troubleshoot problems and share solutionssolutions

Giving Difficult FeedbackGiving Difficult Feedback

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

Congratulating is EASY!

In contrast, problems are…hard to talk about

First, Assess the learner!First, Assess the learner!

How do we assess learners?How do we assess learners?

Establish standards and guidelinesEstablish standards and guidelines

Test knowledgeTest knowledge

Review practiceReview practice

Observe performanceObserve performance

Self-assessment and reflectionSelf-assessment and reflection

Gather impressions of staff, patients, Gather impressions of staff, patients, nurses, colleaguesnurses, colleagues

What are the principles of effective What are the principles of effective feedback?feedback?

General qualities of effective General qualities of effective feedbackfeedback

Should encourage improvement (not Should encourage improvement (not remind us of failure)remind us of failure)

communicated in a way that enables the communicated in a way that enables the learner to use it to their advantagelearner to use it to their advantage

An active process in which both giver and An active process in which both giver and recipient take part and can grow recipient take part and can grow personally and professionallypersonally and professionally

Specific features of good feedback:Specific features of good feedback:

ContractualContractual

Stems from a set of common goals Stems from a set of common goals previously agreed uponpreviously agreed upon

Involves a 2-way discussionInvolves a 2-way discussion

Builds on trustBuilds on trust

TimelyTimely

Should be expectedShould be expected

TimelyTimely

Ask yourself:Ask yourself:– Is this person able to receive feedback right Is this person able to receive feedback right

now?now?– Is this the right place?Is this the right place?

FocusedFocused

Is specific and avoids generalitiesIs specific and avoids generalitiesUses first-hand, accurate data Uses first-hand, accurate data Limited to behaviors that are remediable Limited to behaviors that are remediable

Ask yourself:Ask yourself:– Do I have the facts, the detail?Do I have the facts, the detail?– Can I be specific?Can I be specific?– Is this something the learner can/should Is this something the learner can/should

improve? improve?

AppropriateAppropriate

Objective- based on agreed upon Objective- based on agreed upon standardsstandards

Uses non-evaluative languageUses non-evaluative language

Deals with decisions and actions not Deals with decisions and actions not assumed intentions or interpretationsassumed intentions or interpretations

Avoids “mixed messages” Avoids “mixed messages” (e.g. “you did a good job, but….”)(e.g. “you did a good job, but….”)

ConstructiveConstructive

Is problem solvingIs problem solving

Serves the needs of the learnerServes the needs of the learner

Points to directions for improvementPoints to directions for improvement

Comes to closure and gives sense of Comes to closure and gives sense of future directionsfuture directions

ConstructiveConstructive

Ask yourself:Ask yourself:– Can I be sufficiently calm and objective?Can I be sufficiently calm and objective?

If not, why not?If not, why not?

– Am I willing to stick around long enough to Am I willing to stick around long enough to pick up the pieces if all does not go well?pick up the pieces if all does not go well?

What makes giving feedback so What makes giving feedback so difficult?difficult?

Concerns about Concerns about giving difficult giving difficult

feedbackfeedback

EmbarrassmentEmbarrassment

HumiliationHumiliation

Anger Anger

ConflictConflict

Frameworks for FeedbackFrameworks for Feedback

Be Kind!

Keep it Simple

Think out Loud

Federman’s Triad

Complicating FeaturesComplicating Features

Consider the possibility of the 5 D’sConsider the possibility of the 5 D’s

DepressionDepression

DeprivationDeprivation

DistractionDistraction

DrugsDrugs

Disordered personalityDisordered personality

How do you proceed with giving How do you proceed with giving feedback? feedback?

Conducting the MeetingConducting the Meeting

Begin by seeking to understand learner’s Begin by seeking to understand learner’s state of mind (willingness to hear feedback)state of mind (willingness to hear feedback)

Make a general introduction and then solicit Make a general introduction and then solicit the fellow’s overall thoughtsthe fellow’s overall thoughts– Does he/she think there is a problem?Does he/she think there is a problem?– If so, what is their assessment?If so, what is their assessment?

Meeting Meeting continuedcontinued

Describe problem in detail, actions and Describe problem in detail, actions and consequencesconsequences

Include Include specific examplesspecific examples if has occurred more if has occurred more than oncethan once

Focus on the Focus on the behaviorbehavior not personality or motivesnot personality or motives

State the facts in no uncertain termsState the facts in no uncertain terms

Be open about your reasoningBe open about your reasoning

““From the facts I have related, I am coming to From the facts I have related, I am coming to these conclusions. Am I wrong?”these conclusions. Am I wrong?”

Meeting Meeting continuedcontinued

ListenListen to the responseto the response

Expect some discomfort, defensiveness or Expect some discomfort, defensiveness or disagreementdisagreement

Let the fellow talk it outLet the fellow talk it out

Let the fellow save faceLet the fellow save face

Do not argueDo not argue

Make an effort to be silent and non-Make an effort to be silent and non-verbally supportiveverbally supportive

LISTENLISTEN

Understand the learner’s perspective Understand the learner’s perspective – ““The nurse and I experienced your tone of voice The nurse and I experienced your tone of voice

as disrespectful to the patient when you said... as disrespectful to the patient when you said... How do you see it?” How do you see it?”

Listening and Understanding Listening and Understanding ≠≠ agreeing agreeing

If you disagree, reflect together on the If you disagree, reflect together on the dilemma and see if the learner can propose dilemma and see if the learner can propose a resolutiona resolution

Listening is a KEY tool!Listening is a KEY tool!

Meeting Meeting continuedcontinued

In conversation that follows give positive In conversation that follows give positive supportsupport

Make an action plan. Do you need to Make an action plan. Do you need to meet again? Make arrangements now. meet again? Make arrangements now.

Role-play casesRole-play cases

DirectionsDirections

Pick one person to be the attending/preceptor.Pick one person to be the attending/preceptor.Pick one person to be the learner.Pick one person to be the learner.Others will be active observers.Others will be active observers.

Attending:Attending:Read the case.Read the case.Formulate in your mind the learners strengths and Formulate in your mind the learners strengths and

weaknesses.weaknesses.Consider what is your goal in giving him/her feedback.Consider what is your goal in giving him/her feedback.Conduct the meeting.Conduct the meeting.

Directions Directions continuedcontinued

Learner:Learner:

Read the case.Read the case.

Get in to role.Get in to role.

Observers:Observers: Make note of: Make note of:

Did the preceptor assess the fellow’s receptiveness to Did the preceptor assess the fellow’s receptiveness to receiving the feedback?receiving the feedback?

Was the feedback focused? Appropriate? Constructive?Was the feedback focused? Appropriate? Constructive?

Did the preceptor listen? Provide positive support?Did the preceptor listen? Provide positive support?

Did they make an action plan?Did they make an action plan?

Directions Directions continuedcontinued

Debrief:Debrief:

1.1. How did it go for the preceptor? What went well? How did it go for the preceptor? What went well? What was difficult?What was difficult?

2.2. How did the feedback feel to the learner? Was it How did the feedback feel to the learner? Was it respectful, helpful? Is there a clear action plan?respectful, helpful? Is there a clear action plan?

3.3. Observers, what strategies did the preceptor use? Observers, what strategies did the preceptor use? What was successful? What did not work well? How What was successful? What did not work well? How likely is the learner to improve? How might the likely is the learner to improve? How might the feedback meeting be improved?feedback meeting be improved?

Lessons LearnedLessons Learned

ChallengesChallenges

How to give helpful feedback to a very How to give helpful feedback to a very enthusiastic, hardworking learner who is enthusiastic, hardworking learner who is underperformingunderperforming

How to give feedback to learners who How to give feedback to learners who become defensive or “tune out”.become defensive or “tune out”.

How to give feedback on professionalism, How to give feedback on professionalism, treating staff members poorlytreating staff members poorly

ChallengesChallenges

How to go from generalities “you did great” How to go from generalities “you did great” to specifics, especially if feedback cannot to specifics, especially if feedback cannot timely. timely.

How to give feedback to colleagues, e.g. How to give feedback to colleagues, e.g. amongst peers in lab meetingsamongst peers in lab meetings

Giving feedback as a new attendingGiving feedback as a new attending

ChallengesChallenges

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

Key feedback strategiesKey feedback strategies

Establish expectations earlyEstablish expectations earlyTiming is everythingTiming is everythingPraise in public; criticize in privatePraise in public; criticize in privateEmphasize and repeat important pointsEmphasize and repeat important pointsBe specific, focus on behaviorsBe specific, focus on behaviorsRespect the learner, consider his/her perspectiveRespect the learner, consider his/her perspectiveTake the learner to the “next step”Take the learner to the “next step”Make deposits in the “feedback bank”Make deposits in the “feedback bank”Good technique can be learnedGood technique can be learnedPractice, practice, practicePractice, practice, practice

AcknowledgmentsAcknowledgments

Dave Roberts, M.D. BIDMCDave Roberts, M.D. BIDMC

Sean Kelly, M.D. BIDMCSean Kelly, M.D. BIDMC

Toni Peters, PhD. HMSToni Peters, PhD. HMS

Don Levy, M.D. HMSDon Levy, M.D. HMS

Gary Ferenchick, M.D. Michigan State UniversityGary Ferenchick, M.D. Michigan State University

Society of Teachers of Family Medicine Preceptor Society of Teachers of Family Medicine Preceptor Education ProjectEducation Project

ContactContact

Susan Frankl, M.D.Susan Frankl, M.D.Assistant Professor of Medicine, HMSAssistant Professor of Medicine, HMS

Faculty Consultant, Center for Teaching, Learning and Assessment, Faculty Consultant, Center for Teaching, Learning and Assessment, HMSHMS

Primary Care internist, BIDMCPrimary Care internist, BIDMC

Email: Email: [email protected]

Office: 617 754-0400Office: 617 754-0400