PGY 1 Retreat6/3/13

Thinking about education How to be a good ward resident- small

groups with the Chiefs Changes for next year; administrative

issues; misc…………..

But first………

Working alone, list the top 10 selling automobiles by the number sold…..

Now, repeat this exercise, working in small groups with the people sitting near you……..

1. Ford F-150Numbers of units sold: 434,585

2. Toyota CamryNumbers of units sold: 359,241

3. Honda AccordNumbers of units sold: 331,872

4. Honda CivicNumbers of units sold: 310,753

5. Chevrolet Silverado 1500Numbers of units sold: 306,127

6. Nissan AltimaNumbers of units sold: 302,831

7. Toyota CorollaNumbers of units sold: 286,432

8. Honda CR-VNumbers of units sold: 281,652

9. Ford EscapeNumbers of units sold: 259,567

10. Ford FocusNumbers of units sold: 245,922

Giving Feedback

Keith Armitage Case Western Reserve University

Giving Feedback

Case scenarios

Introduction

Defining feedback The importance of feedback Examples of good and bad feedback Techniques for giving feedback

Feedback is not criticism!! You are a coach

The ability to reflect……an essential part of modern medical practice

Introduction

Most feedback in medical education is self feedback based on the observation of self and others.

Depends on the ability of the learner to give self feedback. Most good internists have this ability. Optimally self feedback is confirmed and

augmented by external feedback.

Defining feedback

Rocket science model “Feedback in the control of a system by

reinserting into the system the results of its performance……if the information is able to change the general method and performance, we have a process which may be called learning.” Humans are more complex; clinical

performance is more complicated than rocket science

Defining feedback

Formative Non-judgmental; presenting information, not

judgmental Rocket science model Neutral, not “good” vs. “bad” “coach”

Summative After the fact, sum of performance, grade “evaluation,” compared to peers “judge”

vs. encouragement

The importance of giving feedback

Obligation in all training situations Learner feels adrift without feedback Misinterpretation of nonspecific signals Bi-directional!

Role of providing information/corrective action

Correction of mistakes in the clinical setting “Vanishing Feedback”

Monthly faculty reminders

Examples of “good” and “bad” feedback

Good Timely, specific, nonjudgmental, devoid of

emotion, private/appropriate setting, given in climate of trust, diagnostic/useful, goal oriented, focused on performance, not personal, supportive, objective, occurrence based, useful

Bad Vague, public, given in anger, non-timely,

personal, “punishment,”

Examples of good and bad feedback, cont

“Your differential diagnosis was O.K., but you might have also considered tuberculosis.”

“Your differential diagnosis was poor/inadequate.”

Techniques for Giving Feedback

The sandwich Beginning and ending with positive

observations Positive feedback- corrective feedback-

positive feedback

Techniques for Giving Feedback, cont.

The Club Sandwich Reinforce success Corrective feedback Affirmation in your belief that the learner

can move forward Plans for moving forward Commitment to support them in their

plans

The Club Sandwich, cont.

I am impressed that you know your patients labs so well

The critical next step is interpreting the labs; for instance, describe the anemia as microcytic, and discuss what this means

I am confident that you can take this next step Do you have ideas about how to do

accomplish this? I would be happy to help work with you on

this issue

Techniques for Giving Feedback, cont.

Micro feedbackSmall opportunities with students as they

arise Capitalize on the moment

Catch them doing something well Good history- he was a tough guy to talk to

Use a nonjudgmental rule statement When patient come in with so and so, it is important to

ask about Give the learn a chance to re do their performance

Why don’t you go back and ask about

Techniques for Giving Feedback, cont.

The “tell me how you think you are doing.”

Take advantage of situations as they arise in the clinical setting.

Focused on goals “Do you want to be the best intern/doctor you

could be?” Turn “negative” feedback into challenge

Techniques for Giving Feedback, cont.

Assess learners level of receptivity to feedback

Encourage learners to ask for feedback Test your hypothesis about what the

problem is Diagnosing your learners

Avoid overloading Follow-up is key

Impediments to giving feedback

Time Inadequate observations Time to meet

Concern over popularity “Not wanting to hurt feelings,” damage

student teacher relationship

Techniques for Giving Feedback, cont.

Avoid focusing on personality traits, unless they affect clinical care

Impediments to giving feedback

Past experiences that were emotionally difficult; fear that feedback will elicit an emotional reaction Concerns about the impact of feedback

leads to no feedback at all

Impediments to giving feedback

Humiliation External emotion that can be avoided if the

teacher provides nonjudgmental feedback Embarrassment

Internal emotion, sometimes can’t be avoided, may be motivational

Dealing with tears/anger Emphasize your willingness to help and their

ability to improve

Now that you are a believer in feedback

Feedback is bi-directional Please take evaluation of your attendings seriously Cumulative data with comments is returned to

attendings Promotion and tenure

Armitage’s general hints for dealing with feedback/administrative situations

Never begin a conversation in anger or assuming the other person is at fault

If you make the issue patient care, you will (almost) always win Always make it patient centered

Kick it upstairs

Mindfulness

Paying attention, on purpose, to one’s own mental and physical process during everyday tasks to act with clarity and insight

(the first thing you do at a code…….)

Habits of Mindful Practitioners

Attentive observation Processing….

Critical Curiosity Tolerating and ‘enjoying’ being wrong

Presence Control of anxiety Egoless focus on tasks Tolerating contradictory ideas Compassion based upon insight

Mindfulness

Understanding your reaction to patients

Incorporating ethics into decision making

Reflection…..! Being purposely mindful

And Finally- another10 minutes on education

Models of learning 5 minute preceptor

RIME

Reporter Interpreter Manager Educator

Diagnosing the learner….

The One Minute Preceptor

What do you think? Why do you think that/what else did

you consider What I am thinking Where do we go from here- positive

feedback and next steps

Teaching the 4 C’s of Effective Oral Presentations on Work Rounds

The 4 C’s of effective oral presentationwill only be successful . . .

. . . if the resident sets the expectations at the start of a rotation

Remember the 4 C’s

COHERENT

CONCISE

COMPLETE

COMPELLING

COHERENT

Introduction (one sentence!) Subjective

Vital signs I/O’s Physical Exam (pertinent)

New study results Review of chart (nurses notes, etc)Assessment and Plan:

CONCISE ( 1-2 minutes)

Essential Pertinent Uncluttered The student should be . . . brief and

lucid The student should speak . . . crisply

and clearly without notes

The 4 C’s algorithm will be successful only with

APPROPRIATE FEEDBACK

“Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all”

- Jack Ende, M.D.

Four steps of clinical teaching Needs assessment Teaching to the learner Feedback Reinforcement

Teaching Clinical Reasoning“On the Fly”

Key Points to Remember

Teach while you work Clinical reasoning is most effectively taught as

you care for patients together, not in a lecture hall or conference room

Live what you teach If you don’t “role model” sound clinical reasoning

as you discuss all your patients, the students won’t think it’s really important

Bottom Line

Teach as you work and live what you teach! Be systematic and think out loud

What are the problems? Foreground and background.

What’s the differential? Focus on likelies and high stakes possibles.

Let your differential drive work-up and management

Long term career goals…

Use elective time for scholarly projects Work with clinical mentors Meet with your PD to discuss….. If you are interested in subspecialty

training- apply at end of PGY2 year..