Beyond the Feedback Sandwich: Fun Tools for Improving Feedback Skills

1. Beyond the Feedback Sandwich:Fun Tools for Improving Feedback Skills

2. Objectives Describe rationale for giving feedback Discuss barriers to giving effective feedback Practice analyzing teaching videos Describe process of giving effective feedback for lifelong learning – including the incorporation of reflection into the process

3. Rationale for Giving Feedback Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or, not at all. Good feedback promotes the skill of reflection, which is essential for the development of expertise and lifelong learning. It’s required by the LCME and ACGME. Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA 2009;302:1330-1331.

4. Feedback (Reinforcement or correction) + Explanation Keeps learner on course to meet goals No judgment against external standards; no matter where learner is in relation to external standards, feedback is always helpful Best if given immediately after the performance or at some time soon after, when the learner still has time to demonstrate improvement If done well, the learner does not feel judged, enhances capacity for reflection, and therefore lifelong professional development

5. Ende Principles of Good Feedback Aligns the goals of teacher and learner Is well-timed and expected Is based on first hand observation Is regulated in quantity and limited to remediable behavior Is phrased in descriptive, non-evaluative language Deals with specific performance Deals with decisions and actions rather than assumed intentions or interpretations Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781.

6. What are the biggest challenges to giving good feedback?

7. Why are educators failing at feedback? 1) Not learner-centered/without awareness of the learner’s perspective or self-assessment 2) Overpowering of affective reactions to feedback / a failure to separate the behavior and the person (for teacher and/or learner) 3) Unsuccessful feedback teaches learner to fear or avoid feedback in the future Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA 2009;302:1330-1331.

8. Domains of feedback Knowledge Skills Attitude Professionalism

9. “Sleeping” Video: Part 1 Take notes on what you observe: What did the residents think of the student? What feedback was delivered? How did the student respond? Discuss with your partner

10. VIDEO

11. “Sleeping” Video: Part 2 Here are the same residents after additional training What was done differently? Do you detect a different structure to the feedback? How did the student respond? Discuss with your partner

12. VIDEO

13. What more could the resident have done? • Make explicit what was learned: “This is an important opportunity to learn how to balance your personal and professional lives. When something in your personal life starts to impact your professional performance, you need to tell colleagues and ask for help in handling the situation and/or ensuring your professional obligations to others are fulfilled.”

14. Professionalism Expected Responsible and reliable Industrious and dedicated Enthusiastic and motivated Appropriately respectful and empathic Honest and trustworthy More advanced • Self directed: takes responsibility for learning and behavior • Actions based on accurate understanding of perspectives and needs of others: including patients, team • Overcomes performance preoccupation to focus on patients and learning

15. The Old Feedback Sandwich Praise Criticism Praise

16. The New Feedback Sandwich* Ask Tell Ask *Lyuba Konopasek, MD; in prep for publication

17. Ask Ask learner to assess own performance first Begins a conversation – an interactive process Assesses learner’s level of insight and stage of learning Less threatening: separating behavior from “self” Promotes reflective practice

18. Tell Tell what you observed: diagnosis and explanation React to the learner’s observation Feedback on self-assessment Include both positive and corrective elements “I observed….” Give reasons in the context of well-defined shared goals

19. Ask (again) Ask about recipients understanding and strategies for improvement What could you do differently? Give own suggestions Commit to monitoring improvement together

20. Limit the Quantity

21. BEFORE Giving Feedback: Prepare Effectively Set a time – major feedback should not take student by surprise Plan what you will say Make sure that you have enough information If feedback is second hand, try to obtain specific, documented behaviorally based information

22. AFTER Giving Feedback:Reflect on How it Went • What was effective? • What could be done differently? • Were you well prepared? • Future strategies • Do you need to document? • Do you need help?

23. Benefits of Ask-Tell-Ask Learner centered incorporating the learner’s perspective Active and interactive Avoids assumptions or judgment Reflection may make it easier to separate the behavior from the person Promotes lifelong skill of reflection These are basic communication skills and allows us to “put the diagnosis before the treatment” Branch J, Paranjape A. Feedback and Reflection: Teaching Methods for Clinical Settings. Academic Medicine. 2002;77:1185-1188.

24. End with Ende “The important things to remember about feedback in medical education are that (1) it is necessary, (2) it is valuable, and (3) after a bit of practice and planning, it is not as difficult as one might think.” --Jack Ende, MD Ende J. Feedback in Clinical Medical Education. JAMA 1983;250:777-781.

25. Acknowledgements Lyuba Konopasek, MD Andrew Mutnick, MD John Encandela, PhD Gingi Pica, MPH Center for New Media and Technology: Michelle Hall, BS Funding: Glenda Garvey Teaching Academy, Columbia University Actors: Maya Castillo Thomas Hooven Benjamin Kennedy Daniel Vo