Feedback in Feedback in Clinical TeachingClinical Teaching

Susan T. Hingle, M.D., F.A.C.P.Susan T. Hingle, M.D., F.A.C.P.

Internal MedicineInternal Medicine

Clerkship DirectorClerkship Director

Associate Residency Program Associate Residency Program DirectorDirector

Associate Doctoring Curriculum Associate Doctoring Curriculum DirectorDirector

AMC Grand Rounds 2010 - Clinical Competency Feedback

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1. DO IT! 1. DO IT!

2. BE NICE!2. BE NICE!

3. BE HONEST!3. BE HONEST!Regina Kovach, M.D.Regina Kovach, M.D.

FeedbackFeedback

• ““AA constructiveconstructive, , non-evaluativenon-evaluative, , objectiveobjective appraisal ofappraisal of performanceperformance intended tointended to improveimprove the learner’sthe learner’s clinical skills.”clinical skills.”

Mariana Hewson, PhDMariana Hewson, PhD

FeedbackFeedback

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

• Jack Ende (1983)Jack Ende (1983)

FeedbackFeedback

• One of the most powerful ways for a One of the most powerful ways for a teacher to teacher to motivatemotivate the learner the learner

• EnhancesEnhances the learner’s strengths the learner’s strengths

• ImprovesImproves the learner’s weaknesses the learner’s weaknesses

• Essential responsibility Essential responsibility to learners, to learners, their patients, and the educational their patients, and the educational programsprograms

““Feedback is a Way to Feedback is a Way to Ensure That Learners Stay Ensure That Learners Stay

On Course”On Course”• This is rocket science!This is rocket science!

• The concept of feedback The concept of feedback goes back to the 1940’s goes back to the 1940’s and rocket engineers: and rocket engineers: when a rocket was when a rocket was launched into space, a launched into space, a radio transmitter sent radio transmitter sent signals back to earth to signals back to earth to track it so adjustments track it so adjustments could be made if it could be made if it veered off course.veered off course.

Jack Ende, M.D.Jack Ende, M.D.

19831983

Feedback and EvaluationFeedback and Evaluation

• FeedbackFeedback• Goal based and Goal based and

objectiveobjective• CoachingCoaching• FormativeFormative• TimelyTimely• Professional Professional

developmentdevelopment

• EvaluationEvaluation• Goal based and Goal based and

objectiveobjective• JudgingJudging• SummativeSummative• After the factAfter the fact• Quality AssuranceQuality Assurance

Feedback = CoachFeedback = Coach

• Timely, immediate, ongoingTimely, immediate, ongoing• DirectDirect• VerbalVerbal• Guiding future performanceGuiding future performance• Face to faceFace to face

Evaluation = JudgeEvaluation = Judge

• SummativeSummative• Not ongoing, occurs at the end of Not ongoing, occurs at the end of

time togethertime together• Assesses whether or not learner Assesses whether or not learner

met performance standardsmet performance standards

Types of FeedbackTypes of Feedback• ReinforcingReinforcing (aka positive) (aka positive)• CorrectiveCorrective (aka negative) (aka negative)

• SummativeSummative– Cumulative, additiveCumulative, additive– Assessed work which contributes to the Assessed work which contributes to the

final outcome of a student’s gradefinal outcome of a student’s grade

• FormativeFormative– Shaping, moulding, constructiveShaping, moulding, constructive

Who Should Give Who Should Give Feedback?Feedback?

• Anyone responsible for trainee’s Anyone responsible for trainee’s evaluationevaluation

• Anyone who directly observes the Anyone who directly observes the learnerlearner

• Anyone with experience and knowledgeAnyone with experience and knowledge

• EXAMPLES: learner to learner, staff to EXAMPLES: learner to learner, staff to learner, learner to preceptorlearner, learner to preceptor

Impediments to Quality Impediments to Quality FeedbackFeedback

• 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 Learner and teacher may have

different perceptions of performancedifferent perceptions of performance

Giving Feedback: Giving Feedback: Do’s Do’s

• DO DO set expectations set expectations• DODO let the learner go first let the learner go first• DODO use language that is specific, use language that is specific,

descriptive and non-evaluativedescriptive and non-evaluative• DODO use “I” when giving subjective use “I” when giving subjective

feedbackfeedback• DODO focus and regulate quantity of focus and regulate quantity of

feedback so it’s not overwhelmingfeedback so it’s not overwhelming

Giving Feedback:Giving Feedback:Do’s Do’s

• DODO consider giving feedback in a consider giving feedback in a sandwich formatsandwich format

• DODO base feedback on direct base feedback on direct observationobservation

• DODO be concerned with decisions be concerned with decisions and actions (not intentions)and actions (not intentions)

• DODO be timely with feedback be timely with feedback

Giving Feedback: Giving Feedback: Don’tsDon’ts

• DON’TDON’T focus on the learner but focus on the learner but on the learner’s actionon the learner’s action

• DON’TDON’T give feedback at bad give feedback at bad timestimes

• DON’TDON’T press if the learner seems press if the learner seems threatenedthreatened

• DON’TDON’T give futile feedback give futile feedback

MethodsMethods• RRRCRRRC

– ReflectionReflection– RulesRules– ReinforcementReinforcement– CorrectionCorrection

• CEDARCEDAR– ClarifyClarify– ExplainExplain– DiscussDiscuss– Agree Agree – ReviewReview

Key Principles to Key Principles to RememberRemember

• 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, Victoria Kaprielian, M.D.M.D.

Margaret Gradison, Margaret Gradison, M.D.M.D.

How Are We Doing?How Are We Doing?

• 2009-2010 SIU RESIDENCY END OF 2009-2010 SIU RESIDENCY END OF YEAR EVALUATION (N=158, 72% YEAR EVALUATION (N=158, 72%

Response Rate)Response Rate)No No ResponResponsese

PooPoorr

FaiFairr

GooGoodd

ExcellentExcellent

Provision Provision of of feedback feedback by full-by full-time time facultyfaculty

44 44 2424 7575 5151

Provision Provision of of feedback feedback by by communitcommunity facultyy faculty

2424 2525 3636 4141 3232

Setting ExpectationsSetting Expectations

• Videoclip 1Videoclip 1• Videoclip 2Videoclip 2

Student PresentationsStudent Presentations

• Videoclip 1Videoclip 1• Videoclip 2Videoclip 2

Interpersonal Skills Interpersonal Skills FeedbackFeedback

• Videoclip 1Videoclip 1• Videoclip 2Videoclip 2

Feedback: One Minute Feedback: One Minute Preceptor ExamplePreceptor Example

• VideoclipVideoclip

PracticePractice

• Vaccination videoclipVaccination videoclip• Patient comfort videoclipPatient comfort videoclip

Feedback: ConclusionsFeedback: Conclusions

• Feedback is a critical part of Feedback is a critical part of learninglearning

• Giving feedback is a skill that Giving feedback is a skill that doesn’t come easily and must be doesn’t come easily and must be practicedpracticed

• Less is moreLess is more– focusfocus– provide often but in small amountsprovide often but in small amounts

FeedbackFeedback

•DO IT!DO IT!

•BE NICE!BE NICE!

•BE HONEST!BE HONEST!Regina Kovach, Regina Kovach,

M.D.M.D.