Delivering Effective Feedback

Calvin Chou, Denise Davis, Ryan LaponisUCSF Department of Medicine

Kara MyersUCSF Department of Obstetrics and Gynecology

Stephanie HarmanStanford Department of Medicine

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Overview of the sessionIntroductions (5 min)Interactive discussions: definitions, goals,

brief literature review (15 min)Small group breakouts with “accordion”

reconvenings (140 min)Final conclusions for feedback

(10 min)Remediation panel (60 min)

IntroductionsNamePosition(s)Where you workLearners you work with

Overview of the sessionIntroductions (5 min)Interactive discussions: definitions, goals,

brief literature review (15 min)Small group breakouts with “accordion”

reconvenings (140 min)Final conclusions for feedback

(10 min)Break (10 min)Remediation panel (60 min)

About feedback"Courage is what it takes to stand up and

speak. Courage is also what it takes to sit down and listen"

Definition and FactsFeedback: specific, nonjudgmental

information comparing a trainee’s performance with a standard, given with intent to improve performance

Fact: Feedback is always being given, consciously or unconsciously, skillfully or carelessly

Suggestion: Feedback is an expression of commitment to the relationship

Van de Ridder et al, Med Educ 2008

Imagine a scenarioThink about a learner Envision a scenario in

which youwould give feedback to that learner

GoalsWhat you hope to gain from this workshop?

(you’ll work on these in small group)

Brief Literature ReviewOptimal reinforcing:corrective

comments ratio: 4:1Students like praise as an ‘ego boost’

but also want specific guidance when they make mistakes

Tying feedback to learner’s goalsUnderstanding the learner’s position helpsCalibrating the amount of feedback

Rudy et al, Eval Health Prof 2001; Kernan et al, Am J Med 200o; Hewson and Little, JGIM 1998; Sostok et al, Acad Med 2002

Feedback StepsSet upGather Information / ObserveARTful Delivery of Feedback

Bienstock et al, Am J Ob Gyn 2007

Overview of the sessionIntroductions (5 min)Interactive discussions: definitions, goals,

brief literature review (15 min)Small group breakouts with “accordion”

reconvenings (140 min)Final conclusions for feedback

(10 min)Break (10 min)Remediation panel (60 min)

Small Groups, Large GroupConvene small groups for

writing, skills practicePractice three individual

components of feedback:Large group mini-didactic

and demonstrationSmall group practice

Set-upCreating a permissive environment for

maximal learningIn context of learner-teacher relationshipIn the spirit of dialogue rather than

downloadingFeatures:

Temporally close to eventIn accordance with learner’s goals: what are

the characteristics of the most exemplary doctors you have seen?

In accordance with learner’s readiness

Small Group Task 1Sub-intros – name; what you have learned

thus far, if anything, that is most alive for you?

Gather informationTranscribe what is

happeningVerbalNonverbal

Record words and/or behaviors to give feedback aboutAvoid “You were…”Practice “I saw…”;

“I heard…”; “I noticed…”

Feedback StepsSet upGather Information / ObserveARTful Feedback

ReinforcingCorrectiveNext Steps

Bienstock et al, Am J Ob Gyn 2007

ARTful SkillsAsk

Self-assessmentCan frame in terms of learner’s previously-

stated goalsRespond

Depends on active listeningUsing empathic words can be helpful

TellYour own assessment and thoughtsBehavioral and specificCan illuminate blind spots

ARTful SkillsAsk

Self-assessmentRecall previously-stated goals from Set-Up

RespondDepends on active listeningUsing empathic words can be helpful

TellYour own assessment and thoughtsBehavioral and specificCan illuminate blind spots

ARTful Reinforcing FeedbackAsk: What do you think you’d like to keep

doing?Respond: gently redirect learner from self-

criticism, and take the opportunity to agree or reflect the learner’s self-assessment

Tell: your own assessment (if anything to add)

The ART cycle continues: ask for reactions to your feedback

ARTful Corrective FeedbackAsk: What do you think you’d like to stop

doing?Respond, Tell (remain as nonjudgmental as

you can!)Continue the ART cycle: ask for reactions to

your feedback

For challenging situations, try: Asking about intention (cultural sensitivity)Responding with empathy or a summaryTelling your perception of how intention and

impact differ

ARTful Next StepsAsk: What do you think you’d like to start

doing?Respond, TellARTful cycle

For learners in high-stakes situations: Agree on action plan and accountability

By when?What would you expect to happen if you can’t /

don’t meet our agreement?

Summary

Adapted from American Academy on Communication in HealthcareBienstock et al, Am J Ob Gyn 2007

Set up Gather Information / ObserveARTful Feedback

Keep (Reinforcing)Stop (Corrective)Start (Next Steps)

Quotation

Without feedback, mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved incidentally or not at all.

Ende, JAMA 1983

Overview of the sessionIntroductions (5 min)Interactive discussions: definitions, goals,

brief literature review (15 min)Small group breakouts with “accordion”

reconvenings (140 min)Final conclusions for feedback

(10 min)Break (10 min)Remediation panel (60 min)

Feedback StepsSet upGather Information / ObserveARTful Feedback

ReinforcingCorrectiveNext Steps

Bienstock et al, Am J Ob Gyn 2007

NET GOALS

RespondHelpful to summarize briefly what learner

has said, and to gently redirect self-criticism for now

Use PEARLS tools to build relationshipPartnership: “I’m happy to work with you on

this”Empathy: “Sounds like it was frustrating to

struggle”Apology: “I’m sorry to hear that you had

difficulty”Respect: “Thanks for sharing your perspective”Legitimation: “This is a really hard exercise”Support: “Let’s see how I can help you with

this”