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Providing Effective Feedback


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Title: Providing Effective Feedback

Providing Effective Feedback
  • Faculty Professional Development
    Series University of Pennsylvania School of
    Medicine September 10, 2008
  • Jennifer R. Kogan, M.D.
  • Lisa M. Bellini, M.D.
  • Department of Medicine

Workshop Objectives
  • Distinguish between evaluation and feedback
  • Discuss principles of effective feedback
  • Identify barriers to feedback
  • Identify strategies to increase feedback and
    improve skills delivering feedback

Feedback vs. Evaluation
  • Feedback
  • Conveys information
  • Formative
  • Current performance
  • Neutral
  • (verbs nouns)
  • Foster learning
  • Evaluation
  • Conveys judgment
  • Summative
  • Past performance
  • Normative statements
  • (adjectives and adverbs)
  • Certification

Benefits of Feedback
  • Assist learners to
  • evaluate knowledge, practice skills
  • define teachers expectations
  • identify strengths/weaknesses without academic
  • remedy deficiencies
  • Assist teachers to
  • evaluate and modify coursework and teaching
  • recognize student progress and achievement

Clinical Education Without Feedback
  • Missed learning opportunities
  • Student insecurity about abilities
  • Inaccurate perception of performance
  • Disappointment and surprise with final

  • Principles of
  • Effective Feedback

Principles of Effective Feedback
  • Related to agreed upon goals
  • Specific
  • Reinforce positive outcomes and behaviors
  • Provide guidelines for improvement
  • Quantity regulated, limited to remediable
  • First hand, objective information
  • Timely
  • Descriptive not evaluative language
  • Accompanied by explanations
  • Includes an action plan

Ende J. JAMA. 1983 250 777-781
  • Feedback during clinical rotations appears to be
    a rather intractable problem
  • in medical education

Irby DM. Acad Med 1994 69333-42
  • What Are The Barriers To Feedback?

What Are Barriers to Feedback?
  • Time constraints
  • Limited information about learner performance
  • Absence of standards of competence
  • Inadequate knowledge of tenets of effective
  • Giving constructive feedback
  • Concern about undesirable consequences for
    student or teacher

"You can observe a lot just by watching."
"You can observe a lot just by watching."
What are barriers to observing students/
residents with patients?
Strategies to Increase Observation
  • Frequent snapshots
  • Pre-rounds
  • First 5 minutes of the outpatient encounter
  • Post-rounds counseling/discharge instructions
  • Observe exam

The Rules for Observation
  • Tell learner you will be coming into the visit
  • Be a fly on the wall
  • avoid interrupting learner/patient dialogue
  • avoid eye contact with the patient
  • avoid interruptions

Structured Approach to Deliver Feedback
Set the Stage
  • Create environment conducive to feedback
  • Elicit learners goals beginning of rotation
  • Establish expectation of continuous feedback
  • Start session by telling learner this is your

Conduct the Feedback Session
  • Elicit learners self-assessment
  • - what was done well
  • - what needs improvement
  • Provide feedback positive and negative
  • Check for understanding
  • Develop action plan/ determine how to monitor

  • Meet again
  • Ensure action plan developed/in progress

The Feedback Sandwich
Feedback Role Plays
Scenario 1
  • Faculty
  • It is the end of the first week of a two week
  • and you are about to meet with the medical
  • who has been rotating with you. The medical
    student is
  • enthusiastic, hard working and interested in
    learning. The
  • student seems to enjoy working with patients, is
    timely and is
  • always asking to see additional patients. You
    are concerned
  • that the student is having difficulty presenting
    a coherent,
  • organized history and physical exam and have
    noticed that
  • the student's notes are similarly disorganized
    with an
  • incomplete assessment and plan. You believe the
  • knowledge base is borderline.

Scenario 1
  • Medical student
  • It is the end of the first week of a four week
    rotation. This is
  • your second core clerkship. You think that you
    have been
  • doing a good job. You really like seeing patients
    and are
  • eager to learn. You have tried to be enthusiastic
    and a team
  • player. The office/ward has been very busy and
    learning how
  • to do a focused patient visit has been a bit hard
    since in
  • Introduction to Clinical Medicine you had 45
    minutes to see a
  • patient and now you only have 15 minutes.

Scenario 2
  • Faculty
  • It is the midpoint of your four-week rotation
    with a medicine
  • core clerkship student. You had told the medical
    student at
  • the beginning of the rotation that you would have
    a mid
  • rotation feedback session. The medical student is
    very bright
  • and has a superior fund of knowledge. He is able
    to perform
  • a focused history and physical exam, synthesize a
  • list, assessment and plan. However, the student
    has arrived
  • late on three occasions and requested to leave
    early another
  • day. Some of the nurses felt he has been curt and
  • The student once got visibly annoyed when
    speaking with a
  • nurse earlier in the week.

Scenario 2
  • Medical student
  • It is the midpoint of your four-week rotation and
    you and
  • your attending are meeting for a planned feedback
  • You haven't been too interested in this rotation
    - you are
  • pretty certain that you are going into Radiology.
    You believe
  • that you have done a pretty good job of seeing
    patients and
  • have tried to come up with differential diagnoses
    for the
  • patients you see. But overall, you are pretty
    bored and are
  • looking forward to your next rotation which you
    think will be
  • much more pertinent to your future career goals.

Scenario 3
  • Faculty
  • You are on morning rounds with your resident,
  • intern and medical student. The team had a very
  • busy night and admitted several sick patients.
  • patient was admitted with dyspnea. The patient
    was thought
  • to have an asthma flare and was given nebulizers.
  • saturations levels were checked throughout the
    night. A CXR
  • was not done and no oxygen was ordered. While at
  • bedside you notice the oxygen saturation of 85
    and the
  • patient in respiratory distress.

Scenario 3
  • Intern
  • You have just finished a very busy call night.
  • You did not have time to see all of your patients
  • before attending rounds. You get to the bedside
  • this patient and begin your presentation. As you
  • begin talking about the physical exam, the
  • picks up the patient flow sheet and notices the
  • hypoxemia. The attending enters the room to find
  • the patient in respiratory distress . . .

Tools to Increase Feedback
Feedback Toolbox
  • Mid rotation feedback forms
  • Read/distribute feedback article
  • Mini-CEX or encounter cards
  • Learners contract
  • Prime learners for feedback
  • review tenets of feedback at orientation
  • prompt students during course
  • teach students how to ask for it