Beyond the Feedback Sandwich - Residents as Teachers - Columbia by dfhdhdhdhjr


									  Beyond the Feedback Sandwich:
Fun Tools for Improving Feedback Skills
• 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
             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
• 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.
• (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
   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.
  What are the biggest
challenges to giving good
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
    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-
           Domains of feedback

• Knowledge
• Skills
• Attitude
         “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
         “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
 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.”
Expected                         More advanced
• Responsible and reliable       • Self directed: takes
                                   responsibility for learning and
• Industrious and dedicated        behavior
• Enthusiastic and motivated     • Actions based on accurate
• Appropriately respectful and     understanding of perspectives
                                   and needs of others: including
                                   patients, team
• Honest and trustworthy         • Overcomes performance
                                   preoccupation to focus on
                                   patients and learning
The Old Feedback Sandwich



    The New Feedback Sandwich*



*Lyuba Konopasek, MD; in prep for publication
• Ask learner to assess own performance first
• Begins a conversation – an interactive process
• Assesses learner’s level of insight and stage of
  – Less threatening: separating behavior from “self”
  – Promotes reflective practice
• Tell what you observed: diagnosis and
  –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
                     Ask (again)
• Ask about recipients understanding and strategies for
  – What could you do differently?
  – Give own suggestions
  – Commit to monitoring improvement together
Limit the Quantity
       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
           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?
                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.
                             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.
Lyuba Konopasek, MD
                       Glenda Garvey Teaching
 Andrew Mutnick, MD
                          Academy, Columbia
John Encandela, PhD            University
  Gingi Pica, MPH
Center for New Media        Maya Castillo
  and Technology:         Thomas Hooven
  Michelle Hall, BS      Benjamin Kennedy
                             Daniel Vo

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