Feedback
Providing Feedback is part of Talking about performance, the third “T’ in the “3T Teaching blueprint” (shown below).
“Talking about performance” is made up of two parts, feedback and evaluation. Feedback and evaluation are separated because they are different entities and they serve different purposes. This section focuses on Feedback.
Feedback. What, Why, How
Below is the “What”, “Why”, & “How” of Feedback. Each section provides more information about what feedback is, why it’s important and how to give feedback.
What is Feedback?
Feedback is the process in which an attending verbally informs his/her learner (student or resident) on their performance. It is often informal and done at high frequency, often multiple times during the day. It is also done at the end of the day. The purpose of feedback is to give information to the leaner so they can use it to correct mistakes and reinforce positive performance. Feedback is not tracked by GME or medical schools.
Why feedback is important.
Giving good feedback helps you, helps them (residents & students) and helps us (GME). Click below to find out more.
Global reasons for Feedback
The dynamics between the learner and the teacher behave like a system. The simple, yet effective, definition of a system is:
The teacher and learner are elements, they inter-connect and they have a purpose. System scientists have shown that feedback is critical to the long term health of any system.
Feedback is how a system knows to re-calibrate and adjust its behavior. Without feedback, systems can show dangerous behavior that can lead to destructive consequences. Without feedback, a system will quickly fail.
We all know that it would not take very long for something bad to happen in the situation pictured.
Nobody would ever think of doing anything like this because it’s obviously dangerous and destructive. It’s important to understand that failing to provide feedback to residents and students can be just as dangerous as doing surgery without monitoring the vital signs.
Feedback Helps You!
Correctly doing feedback is important to YOU for several reasons.
1. It builds attending-learner rapport.
2. It increases resident “buy in”. When residents “buy in” they more often give you 110% effort. This is because it lets them know that you truly care about their wellbeing and growth.
3. It increases resident attention to detail when taking care of your patients.
Improving attending-resident rapport and increasing resident “buy in” helps the resident become productive members of your health care team and increases delivery of great patient care.
Feedback Helps Them!
Feedback helps residents and students in the following ways
Feedback is the primary means in which a resident can gauge how he/she is progressing.
“A resident DOES NOT know if he/she is underperforming/over performing if YOU do not tell them”.
Residents are essentially blind to how they are doing. What’s visible to the attendings is not visible to the residents.
If the resident does not know what to continue doing, what to stop doing and what to start doing, he/she cannot grow.
It is also why the “lack of giving feedback” is one of the most common resident complaints about attendings.
How to give feedback
The content below details some methods of giving feedback as well as some common pearls and pitfalls.
The “Sandwich” strategy
The “Sandwich” method is the traditional method for giving feedback to medical learners (students, residents, and fellows). It’s a directive method which involves the attending doctor directly telling the learner how he/she performed. The “sandwich” method architecture is as follows
- Step 1: Provide the learner with feedback on something that they did well.
- Step 2: Provide the learner with something constructive (i.e. negative feedback).
- Step 3: Finish with providing the learner with more positive feedback.
Essentially, the sequence is positive feedback-negative feedback-positive feedback. The hope is that the sandwiching of the negative (constructive) points between the two positive points makes the feedback more palatable. In theory this makes sense, it includes an initial positive frame and a positive end effect. Which have been shown to create more positive feelings toward messages.
Unfortunately, in reality, most learners have found the “Sandwich” to be a painful, unfulfilling, experience. Learner’s are usually very familiar with the positive-negative-positive aspects of the “Sandwich” and they often ignore the positive aspects and only hear the negative feedback.
Many attendings also feel the “Sandwich” method is sub-optimal. Attendings often state that delivering feedback using the “Sandwich” method feels difficult, harmful and ineffective.
The “Ask-Tell-Ask” strategy
The “Ask-Tell-Ask” method is Dr. Stanley’s preferred method for giving feedback to medical learners (residents and medical students). This method uses a collaborative approach as opposed to the directive approach of used by the more traditional feedback methods (see “sandwich” approach above).
The “Ask-Tell-Ask” steps are outlined below
- Step 1: The attending “Asks” the learner to reflect on his/her performance. This can be something the learner thinks he/she did well and/or something the learner thinks he/she could do better. Dr. Stanley likes to ask “Name one thing you thought you did well today and one thing you feel you could have done better”.
- Step 2: The attending “Tells” the learner his/her thoughts about the learner’s performance. Learners tend to be more comfortable with the “Ask-Tell-Ask” method because it let’s them give input and contribute to the feedback discussion in a non-threatening manner. They are typically less defensive because they led the discussion. A lot of attendings feel that the “Ask-Tell-Ask” approach feels safer, easier, and more beneficial when compared to the more traditional feedback methods.
- Step 3: The attending “Asks” the learner to come up with a plan step to reinforce positive performance and to correct negative performance.
A lot of attendings feel that the “Ask-Tell-Ask” approach feels safer, easier, and more beneficial when compared to the more traditional feedback methods.
Feedback Video
Feedback Pears & Pitfalls
AVOID VAGUE FEEDBACK
Feedback should be specific. Vague feedback such as “read more” or “work on your differentials” or “good job” are not very helpful.
The best feedback describes the specific event/situation with details and your reasoning. Specifically, the feedback should include
- WHAT they did well/did not do well.
- WHY they did it well/did not do it well.
- HOW to reinforce strong work/work on the problem.
An example of effective feedback is
- “You should read up on aortic dissection and pulmonary embolism because you seemed to have trouble differentiating these two conditions. You should focus on how each condition presents and how to differentiate the two conditions because the treatment for a PE can be lethal if given to a patient with an aortic dissection, so making the correct diagnosis is critical”
When giving feedback, at a minimum, you need to include specifically WHAT they did well/did not do well and WHY they did it well/did not do it well. This should refer to a specific event/instance.
When using the “Ask-Tell-Ask” method, learners often try to give vague answers during the “Ask” steps. It is important to only accept answers that refer to specific situations. The attending should always encourage the learner think of specific situations when reflecting on his/her performance.
RAPPORT
For feedback to be effective, rapport between the attending and the learner (medical student and/or resident) must exist. If the learner does not feel that the attending has his/her best interest in mind, the feedback will be rejected, regardless of the method used. It’s imperative for the attending to have the resident’s best interest in mind when giving feedback. This can’t be stressed enough.
TIMING MATTERS
The timing of the feedback can be important. A general rule is to praise in public and criticize in private. This is especially true when using the “Sandwich” method of feedback.
SIGNALING
During feedback sessions, it’s common for learners to fail to recognize they are getting feedback. It has to do with the learner’s level of signal-to-noise. As a rule, the clinical environment is unfamiliar to most learners (especially early learners) which means there is a lot of cognitive noise. This makes is tough for learners to pick up certain signals, feedback is no exception. This problem has an easy solution, simply tell the learner that you are “giving them feedback”. This primes them to pick up the “feedback signal” and it frames the entire discussion as a “feedback session”. This is especially important when using the “Ask-Tell-Ask” method for feedback.
Feedback Myths
Below are several myths that are commonly held regarding feedback and evaluation.
This is a commonly held attending misbelief. The truth is, most attendings CAN provide accurate/quality resident evaluations.
In fact, the resident’s attending has the most situational awareness about the resident’s performance on shift. So the attending’s evaluation is actually the best source of information for the residency program.
Best Practice Strategy: Attendings can use a simple method to ensure that their evaluation is accurate and of quality. The method is as follows: first, use the Ask-Tell-Ask feedback approach (see section on Feedback. How?) to safely provide feedback to the resident. Then use the information gained from the feedback to make the resident’s written evaluation.
Many attendings have “The resident will hate” fear when it comes to feedback and evaluation. Coming soon will be a discussion on how to make this fear go away.
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