Giving Effective Feedback

							 Using the RIME Method for
 Effective, Brief Evaluation &
Feedback in the Clinical Setting
                    Objectives

1. Explain the purpose of the RIME feedback
   method.
2. Describe the RIME Schema and associated
   behaviors/competencies.
3. Practice using this method to give feedback.
4. Reflect on the outcomes of using this method and
   consider ways to improve your application of the
   method in the future.
                            What is it?

                        The R-I-M-E Method
              (Reporter-Interpreter-Manager-Educator)

 Provides a systematic, objective framework to “diagnose” a learner’s
  functional level & then provide recommendations on how to move to
  the next level;

 Uses manageable, observable & easily understood concepts that
  demonstrate growing levels of professional knowledge & behavior;

 Facilitates focused verbal assessment of learners on competencies
  such as problem identification, reasoning, communication, physical
  examination, written documentation, & professional attributes;

 Allows clear, brief, meaningful & useful feedback to learners in a
  timely manner.
                                  How Does it Work?

The RIME method, developed by Louis Pangaro, MD

   allows brief, constructive & timely evaluation & feedback,
   uses a simple level of competency rubric,
   reinforces appropriate behavior,
   motivates students via immediate, brief, focused & constructive feedback,
   can improve inter-rater reliability by providing a systematic rubric.

The RIME schema describes expected cognitive & behavioral progression in the development of
   medical skills. Instructors use the competency schema to:

   quickly assess student performance,
   decide what skills to provide feedback on at each teaching opportunity,
   frame their feedback so as to encourage significant improvement.



Pangaro, LN. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999
   Nov;74(11):1203-7
                      Reporter


The learner:
 accurately gathers & clearly communicates the
  clinical facts on his/her patients,
 demonstrates a clear sense of responsibility,
 develops consistency in “bedside” skills.


These skills must be mastered as a criterion for passing
 the clerkship (and to fulfill competencies required
 for graduation).
                            Interpreter

 Transitioning from “reporter” to “interpreter” is
  essential for a third year student, but often very
  difficult.

 Clinical test data provide an “interpreting” opportunity
  that requires:
     a high level of knowledge,
     skill in selecting clinical findings that support the diagnosis,
     skill in applying results appropriately in a specific case.


 The student must transition emotionally & cognitively
  from “bystander” to active participant in patient care.
                       Manager

 Requires increasing knowledge, confidence &
  judgment in deciding when action needs to be taken
  and in selecting among & proposing options for
  patient care.
 Student must learn to tailor the plan to the patient’s
  specific circumstances & preferences.
 Can’t expect that a student’s diagnostic & treatment
  suggestions will always be “right”– so it’s best to ask
  them for 3 options.
                           Educator

 Success in each prior step depends on self-directed
 learning & mastery of basics.

 An advanced trainee (educator level) will demonstrate:
     the drive to look for evidence on which clinical practice can be
      based,
     the skill to recognize evidence that can stand up to scrutiny,
     going beyond the required basics to read deeply and share new
      learning with others,
     the insight to identify questions that are important to research in
      more detail,
     the maturity & confidence to share leadership in educating the team
      (and even the faculty).
RIME Schema         Behaviors for Feedback
Reporter       Reliably, respectfully, honestly gathers information from
                patients & communicates clearly with faculty.
               Gets the basic work done.
               Answers the “what” questions.


Interpreter    Presentation shows selectivity, prioritization & implies
                analysis.
               Demonstrates active involvement in thinking through the
                patient’s problems, interpreting the data & acquiring the
                knowledge to offer a reasonable differential diagnosis.
               Answers the “why” questions.


Manager        Works with patients on diagnostic & therapeutic decisions,
                continually developing expertise -- as demonstrated in
                clinical planning.
               Consistently answers “how” to resolve problems.


               Personal planning & reflection demonstrate a commitment
Educator
                to develop expertise.
               Demonstrates ongoing efforts to self-correct & improve.
           Tips for Using the RIME Method

 Evaluate or “diagnose” the           Avoid personal biases &
  learner based on current level of     comparisons with others when
  knowledge & skill development,        assessing the learner’s
  as well as any noticeable             performance.
  improvements in performance.
                                       It is most effective to focus first
 Recognize that the learner’s          on what the learner has achieved,
  development is in process, and        and then briefly highlight areas
  consider performance in that          where you see the possibility for
  light.                                further growth.

 Carry a pocket-sized card that       Maximize the learner’s
  summarizes the RIME levels so         motivation to improve by using
  you can refer to it quickly when      constructive, encouraging words
  giving feedback, and can share        & giving clear examples of how to
  the rubric with the learner.          change his/her behavior.
                           Quick Review

1.   The RIME feedback method is designed to provide:

     a. a detailed & comprehensive method for competency-based
         feedback & evaluation.
     b. a quick & easy method for meaningful, competency-based
         feedback & evaluation.
     c. a system of feedback & evaluation that allows learners to guide the
         feedback process in order to improve their clinical skills.

2.   One example of a competency that can be evaluated effectively using
     the RIME method is:

     a. showing commitment to self-correction & self-improvement.
     b. accepting that, as learners, the resolution of problems will be above
         their skill level.
     c. always relying on the attending or resident to outline a treatment
         plan.
                         Quick Review

3. To give effective feedback to a student via the RIME method, you:

    a. Ask her to write a comprehensive H&P, then present the patient to
    you with differential & detailed recommendations for a treatment
    plan. After finishing your rounds for the day, you review the student’s
    written recommendations and then give her feedback the next time
    she rounds with you.

    b. Check to see if she has transitioned from an observer to an active
    participant in the patient’s care by asking her for a diagnosis &
    treatment plan (“Manager” level). You then reinforce any accuracies
    in her diagnosis & treatment plan, and ask her opinion about
    alternatives you think she should consider.

    c. Point out the fact that her diagnosis & treatment suggestions are
    inaccurate and unfounded based on details of the patient’s history that
    the student seems to have ignored. You suggest that, if she wishes to
    become a competent physician, she should be more thorough and pay
    better attention to details.
                      Quick Review

4. To improve your application of the RIME method
   in the future, it would be helpful to:
   a. Reflect on the fact that the student is still developing
      clinical skills, so you should focus on pointing out errors
      and shortcomings to help improve performance in the
      future.
   b. Realize that the student will likely be able to perform
      better next time if you point out how well student “x”
      performs, and set that as a goal for the student to work
      towards.
   c. Reflect on the student’s response to your feedback, and
      adjust your style of communication in the future to
      provide encouragement for her to continue learning &
      improving.
                           Answers

 1. (b) much of the value of the method is due to it’s ease of use
        & brevity. Therefore, “a” is wrong because it suggests
        a long, complex process; and “c” is wrong because the
        instructor, not the student, should guide the process.
 2. (a) is correct because it reflects a developing competency,
        while “b” and “c” do not indicate any motivation to
        develop skills of analysis & planning.
 3. (b) reflects appropriate use of the RIME model & skill
        in encouraging the learner; “a” involves too much time
        lapse, and “c” discourages the learner.
 4. (c) will help you reframe your teaching to encourage
        the student to do better; while “a” & “b” will
        reinforce your thinking that the student is a poor
        performer and will likely lead to behaviors that will
        discourage her improvement.