Beyond the Feedback Sandwich: Fun Tools for Improving Feedback Skills

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

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.

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

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

feedback?

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.

Domains of feedback

• Knowledge

• Skills

• AttitudeProfessionalism

“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

VIDEO

“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

VIDEO

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.”

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

The Old Feedback Sandwich

Praise

Criticism

Praise

The New Feedback Sandwich*

Ask

Tell

Ask

*Lyuba Konopasek, MD; in prep for publication

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

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

Ask (again)• Ask about recipients understanding and strategies for

improvement– 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 information

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.

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