REFLECTIVE FEEDBACK CONVERSATIONS Challenges & Strategies

Karen Spear Ellinwood, PhD, JD, EdS Director, Faculty Instructional Development Residents as Educators Program

Disclosures – None; No Conflicts

Related Resources

Eligible for CME

• Course on feedback

• 3 credits (between 2-3 hours)

• FREE to all UA CoM faculty

• Part of Department of Medicine CME series

Not eligible for CME

• Course on feedback

• 1.5 hours

• Audience: Residents as educators

• FREE

• Self-directed learning or flipped classroom

• 2 versions: iBook & PDF

• @ FID website (http://bit.ly/rae-course)

This presentation is based upon the key concepts presented in these courses.

Session Objectives

At the conclusion of this interactive session, participants should be able to:

1. Distinguish between “evaluation” and “feedback”.

2. Define the reflective feedback conversation.

3. Evaluate sample comments applying this model.

4. Describe strategies for addressing challenges in feedback situations.

DISTINGUISH FEEDBACK FROM EVALUATION Defining Terms

Evaluation

• Evaluation tells the learner that they did well, poorly or somewhere in between.

What

How

Why

• Tells the learner WHAT they did and HOW they did it

• Offers GUIDANCE upon which the learner can act

Feedback

What Next

Video Example

•Consider the physician’s comments.

•Apply the definitions of feedback and evaluation.

•Characterize the statements as Evaluation OR Feedback

Source: Cho E. & Lin M. Giving Effective feedback in the Emergency Department. San Francisco General hospital Department of Emergency Medicine. UCSF and SFGH; 2007.

Is this feedback or evaluation?

Evaluation

Feedback

Actionable

Source: Choo E. & Lin M. Giving Effective feedback in the Emergency Department. San Francisco General hospital Department of Emergency Medicine. UCSF and SFGH; 2007. (Used with permission of the authors received March 4, 2015; full copyrighted material available on YouTube.)

The Physician’s Comments

What was said…

• "You had a great shift."

• "You did a good job."

• "You are really enthusiastic."

• "You're a great team player."

• "You have a good attitude."

• "People like working with you."

Should be characterized as…

Evaluation

Feedback

Analysis

The remarks tell the learner she’s doing well.

The remarks are not feedback because they do NOT …

Describe specific behaviors or skills to maintain or improve.

Include actionable information to improve

Analysis - Notice anything else?

• The learner asked a couple of times, "Is there anything specific you think I can work on for next time?"

• The supervisor never responded, except to repeat the that the learner did a good job.

REFLECTIVE FEEDBACK CONVERSATIONS A Way to Make Feedback Actionable

The Reflective Feedback Conversation Model combines attributes of reflective practice with constructive feedback in a conversational approach.

DESCRIBE Relevant, Observable Behaviors

Invite SELF-ASSESSMENT

Provide ACTIONABLE GUIDANCE

Fram

e

Feedback

As a

CONVERSATION

Some Familiar Challenges

Students might…

• Not be receptive to corrective feedback

• Feel anxious about what you think and what you’ll say on formal assessments (grades)

• Think they know “it” all already

• Focus on positive feedback and disregard the rest

• Not know how to respond to corrective feedback

• Not be accustomed to participating in feedback as a conversation {They think feedback is something you do}

Go to POLL

Prepare the student for receiving feedback

You want to offer feedback Tell them …

You expect their active participation

You’d like to hear their perspective, ideas, concerns

You want this to be a conversation

Frame Feedback as a Conversation

Describe relevant, observable behaviors

• Describe WHAT the student did

• Be specific – In other words, describe HOW the student…

• Elicited the history regarding the patient’s use of the new medication

• Conducted breathing assessment

• Explained how to use the inhaler

• Dealt with an awkward or challenging moment

• Presented patient’s case

• Consulted with another service

Offer Both Constructive Compliments & Correction

Invite Self-assessment

• Was there something that went smoothly?

• Did the student prepare for the experience in a way that they think made a difference?

• Was there something particularly challenging?

• In what ways? • How did the student

address it? • Did prior experience

help?

Encourage the learner to tell you how they think the shift or encounter went.

Self-assessment Promotes…

• Self-awareness…

• Self-regulation

• Identification of gaps in your perspective versus the student’s

DESCRIBE Relevant, Observable Behaviors

Invite SELF-ASSESSMENT

Provide ACTIONABLE GUIDANCE

Fram

e

Feedback

As a

CONVERSATION

Reflective Feedback Conversations

Reinforcing Corrective

LET’S EVALUATE FEEDBACK Video Example

Real Examples

What do you think about this example?

Evaluation

Feedback

Actionable Guidance

Source: Choo E. & Lin M. Giving Effective feedback in the Emergency Department; ALiEM (2007)

Let’s assess

• http://bit.ly/rae-pulmonary *

* Poll remains open after this presentation is posted online.

https://www.polleverywhere.com/multiple_choice_polls/y5y3e1ohc4SUpS2?preview=true

https://www.polleverywhere.com/multiple_choice_polls/VnO6DV78YRPNEUs?preview=true

https://www.polleverywhere.com/multiple_choice_polls/S3x5SVgEOfnFnmp?preview=true

ANALYSIS OF VIDEO

What was constructive about the attending’s remarks on the EXAM?

• Mentor: "She definitely had some abnormalities that I picked up on my exam. Did you happen to pick up on any of them?"

• Learner: "I didn't actually. I thought the exam was pretty normal."

• Mentor: "So what do you think about with any patient who walks through the door with a fever and a history of drug use?“

Component: Invite self-assessment • The attending’s question

invites the student to reflect on how she did the exam and to think about what she might have looked for but didn’t.

How could the attending make her remarks more constructive?

• The attending could ask the student to describe:

• How she prepared for the exam

• Did she consider what she might expect to find given the patient’s history?

• Did she look for those indicators?

Component: Describe relevant, observable behaviors as "constructive compliment"

• Mentor: "The way that you teased out the drug use history was absolutely essential to finding out what was going on with her [the patient]."

• This statement tells the learner WHAT they did well, but does not specify what it was about the learner’s questioning of the patient that she considered to be productive.

How could the attending improve this complimentary feedback?

• The attending could provide an example of a question the trainee asked that helped to "tease out" the drug use history.

• She could explain whether she thought it was the framing or phrasing of the question that made it possible to “tease out” the patient’s drug use history.

• If the question itself was not the determinant, the attending could identify the nonverbal communication style that might have helped elicit the necessary information from the patient.

Whether it’s Narrative or Face to Face

Ask yourself….

Is my feedback actionable?

• Did I include specific relevant behaviors that tell the student what they did?

• Did the example explain WHY the performance was good, bad or mediocre?

• Did I provide GUIDANCE the student can use to improve?

Did the attending offer actionable guidance?

• The mentor asked the student what she should have anticipated

• In response to the student’s summary, the mentor advised the student she was …

• Was on the right track in looking for a rash, and

• Should re-examine the patient, keeping in mind the things they identified that would be reasonable to look for in this clinical situation.

Yes!

This guidance is actionable because the learner now knows what to look for and how to examine the patient for these potential findings.

WHAT’S WRONG WITH THE FEEDBACK SANDWICH? Focuses in practice on Saving Face

What about the Feedback Sandwich?

• In theory: Supposed to help the student receive the “bad” with the good.

• In practice: Aims to save face of the feedback recipient, or to help the instructor avoid being the “bad guy”.

Kogan J. How to evaluate and give feedback. In, L.W. Roberts (ed.), The Academic Medicine Handbook: A Guide to Achievement and Fulfillment for Academic Faculty. Springer:New York, pp. 91--‐101; 2013.

• If the main point of the comment is to make sure the student saves face, you’re probably not helping them.

It’s okay to empathize. But, avoid commiserating

CHALLENGES & STRATEGIES Re-establish or Clarify Expectations

Translate the Accusatory YOU

Promote Reflective Engagement through Inquiry

STRATEGY #1 Re-establish or Clarify Expectations

Strategy #1 - Re-establish or Clarify Expectations

Scenario • Student conducts

examination of patient with history of asthma and COPD.

• Patient started non-steroidal drug for daily use to improve capacity for restoring normal activity.

• Patient is a shipping clerk and does occasional heavy lifting.

What the student says/does

Student: How do you like this new

medication, Mr. Smith?

Smith: I like it real well. [coughs]

Student: Let me listen to your lungs.

[Applies stethoscope to chest and back; asks patient to take a few deep breaths; patient coughs but recuperates quickly]

Student: You sound pretty good

considering how you were last time. Dr.

Attending will come in to check you too.

Do you have any questions?

Re-establish or Clarify Expectations Scenario • Asthma/COPD Patient

• Describe what the student did well.

• Describe what the student poorly.

• How could we CLARIFY expectations for the student’s

performance in this type of encounter?

• How could we ELICIT from student their understanding of our

expectations for performance in this type of encounter?

STRATEGY #2 Translate the Accusatory YOU

Strategy # 2 - Translate the Accusatory YOU

You asked the patient for their subjective impression of the new medication. You should have asked about how the patient’s breathing was with respect to specific daily activities at home and at work. How can you tell from your interview whether Mr. Smith made sufficient improvement to return to full duties at work? Now, you’ll have to go back and ask the right questions to determine whether he’s had sufficient improvement.

Let’s Translate the Accusatory YOU

I/We/It Translation

You asked the patient for their subjective impression of the new medication. This is helpful, but we need to know more in order to determine if Mr. Smith has made sufficient improvement to return to full duties at work. Typically, we test the patient’s capacity and oxygen level, as an objective measure, using a spirometer. Also, I ask patients about how their breathing is while their performing specific daily activities at home and at work, and compare this to information from the prior visit. This gives me a good idea whether the patient has made sufficient improvement or not.

I/We/It Translation

When we go back in the room, let’s ask questions that will help us determine, for example, how much weight he can lift before his breathing becomes distressed or before he coughs uncontrollably and has to use an inhaler.

Let’s see if there are differences in the activities he does at home and at work that cause breathing difficulties. I also like to ask how long does it take after using the medication before he can breathe with little difficulty.

I’ll let you start off and I’ll jump in as needed.

I/We/It Translation

• Wordier, because of its indirect style

• Takes a bit longer to communicate (not much)

• Softens the impact without losing the message of WHAT needs to improve and HOW to improve it

And there’s always modeling

YOU is OK! When you are intending to compliment the student

And, sometimes, you have to say YOU when you are being corrective because the circumstances might require you to be more direct.

STRATEGY #3 Promote Reflective Engagement through Inquiry

Strategy #3 - Promote Reflective Engagement through Inquiry

• Reflective Inquiry strategies aim to:

• Promote reflective engagement, and

• Identify behaviors, attitudes or skills that the student should learn or improve.

Ask questions that invite the student to… articulate reasoning

Asthma/COPD Exam Scenario

• Student suggested Mr. Smith should continue the new medication.

• What did you notice during your exam or learn from the patient interview that makes you feel we should recommend that?

• “I noticed you listened to Mr. Smith’s breathing normally and with deep breaths.”

• What information are we seeking to learn from that exam?

• How will it help us determine next steps in Mr. Smith’s care?

• Is there another exam we could do? How would it help us?

Ask questions that invite the student to… weigh the evidence

• Describe how to determine whether the evidence is sufficient to determine next steps or take specific action

• Asthma/COPD Exam Scenario

• Does we know enough to warrant continuing this patient on the new medication?

• Describe what we know so far about the patient’s condition and response to the new medication, and let’s think aloud about whether we need to know more before recommending continuation of the new medication or not.

Ask questions that invite the student to… Explore other perspectives on the encounter

• Asthma/COPD Exam Scenario

• Let’s brainstorm other perspectives to see if we’ve covered all the bases.

• What would the patient’s employer want to know about whether Mr. Smith should return to certain work activities?

• What would the patient want to know about activities he should do or not do at home?

• What would I want know before I sign off on a return to certain duties?

Exit survey

• http://bit.ly/rae-exit

References

Reflective Feedback Conversations

• Cantillon P & Sargeant J. Giving Feedback in clinical settings. British Medical Journal 337:1292-94; Nov 2008.

Formative Feedback

• Chan PE, Konrad M, Gonzalez V, Peters MT & Ressa VA. The Critical Role of Feedback in Formative Instructional Practice. Intervention in School and Clinic. published online 29 May 2014 accessed at http://isc.sagepub.com/content/early/2014/05/23/105345121 4536044.

• Kogan J. How to evaluate and give feedback. In, L.W. Roberts (ed.), The Academic Medicine Handbook: A Guide to Achievement and Fulfillment for Academic Faculty. Springer:New York, pp. 91‐101; 2013.

Video Excerpts Used with Permission

• Choo E & Lin M. Giving Effective feedback in the Emergency Department. San Francisco General hospital Department of Emergency Medicine UCSF and SFGH; 2007 (copyrighted material available on YouTube at http://youtu.be/DbfISZjG9mU.

EVALUATION Please take a minute to offer feedback on this workshop and to the facilitator.

Karen

THANK YOU!

http://bit.ly/fid-fac