New Directions in the Practice of Giving Feedback

David Hatem MDMark Quirk EdD

Sophie Davis School of Biomedical Education

Faculty Development WorkshopNovember 17, 2008

http://www.umassmed.edu/cfdc

New Directions in Feedback:

Focus on Feedback

Links to Articles

Slides

Objectives

Review Feedback Discuss ways to bring feedback to a higher

level by focusing on clinical expertise Insure continuity of learning through

feedback and action plans

Introduction: The Stepping Stones Exercise

Introduce yourself to group members by: Picking 3-5 significant events or people who are

important in getting you to where you are today (your “stepping stones”)

List them in chronological order Tell the members of your small group about your

stepping stones

Debriefing the Stepping Stones

What effect does this exercise have on the formation of your group?

What effect, if any, will it have on explaining and allowing different perspectives to be heard in the group?

What effect will it have on feedback?

Following up on the Spirit of Stepping Stones: Checking In

What is it like to be in this group today, right now? Ask students to briefly report or “check in” about

anything that has happened since the last meeting that they think is affecting their presence in the group today

Often hear about Good news Personal or professional challenges Simple readiness to learn

The Goals of Feedback

Ensuring that the learner Ensuring that the learner improves, while at the same time improves, while at the same time maintaining his/her self-respectmaintaining his/her self-respect ..

Effective Feedback

Encourages self-assessmentEncourages self-assessment Covers positives and negativesCovers positives and negatives Refers to specific, observed behaviorRefers to specific, observed behavior Limited in the amountLimited in the amount TimelyTimely Occurs in an appropriate placeOccurs in an appropriate place Ends with an action planEnds with an action plan

The Language of Feedback

Call it feedbackCall it feedback Is attentive to the power differentialIs attentive to the power differential Is non-judgmental (“I” statements v “you” Is non-judgmental (“I” statements v “you”

statements)statements) Label the subjective (“I wonder if…” “My Label the subjective (“I wonder if…” “My

impression was…”)impression was…”) Assesses reaction to feedbackAssesses reaction to feedback

Elevating Feedback to a Higher Level

Fostering the Development of

Clinical Expertise

Objectives

Define ‘high level skills’ that constitute clinical expertise

Use questioning to ‘deliver’ feedback around these skills

Negotiate an action plan to conclude the delivery of feedback and propel learning

What are the high level skills of clinical expertise?

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are needed to see this picture.

Thinking about one’s own or

another’s thinking or feeling

• Anticipates patient’s reactions (and plans accordingly)

• Reflects on potential bias that could impede problem-solving

• Reads patient’s clues and adapts

• Recognizes and regulates own tendencies (e.g., to control the interview)

• Understands the patient’s concern and perspective

Effective Clinical Communication and Problem-solving: A Metacognative Approach

Why Focus on These Skills?

1.1. Didn’t know enough about the diseaseDidn’t know enough about the disease

2. Didn’t Reflect on Potential Biases

Bordage, 1999Bordage, 1999

Residents: Why did you miss dx past year?Residents: Why did you miss dx past year?

• Was influenced by a ‘similar’ case

• Was in denial of an ‘upsetting’ dx

• Was in too much of a hurry

• Let the consultant convince me

• Didn’t reassess the situation

• Pt had too many problems at once

Reflection as a ‘Debiasing’ StrategyReflection as a ‘Debiasing’ Strategy Croskerry, Acad. Med. 2003Croskerry, Acad. Med. 2003

“A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics and biases.” (Cognitive Dispositions to Respond -- CDRs)

Metacognition is an effective strategy -- “stepping back from the immediate problem to reflect on the thinking process

CDRs should be an Essential Part of Teaching Problem-solving

(Four of 30)(Four of 30)

Posterior probability -- estimate of likelihood is unduly influenced by what has gone on before in physician’s and or patient’s past

Omission bias -- rooted in the ethical principle ‘Do No Harm.’ Events that occur in natural progression of a disease are more acceptable than those that result from physician intervention

Sutton’s slip -- dx possibilities other than the obvious are not given enough consideration

Anchoring -- tendency to ‘lock on’ to salient features in the initial presentation and failing to adjust

Acute Left Shoulder Pain

1. Previous patient with MS was in acute crisis and had to be sent to the ER2. This patient with shoulder pain was lifting a motorcycle engine into place four days ago when pain developed3. Doctor on call recommended Advil4. Pain persisted5. At this visit

- Shoulder and cardiac exam normal- ECG - normal- Didn’t admit to ER despite the severe pain

6. Next day the patient died en route to the ER7. Reflection: I could have logically sent him to the ER but:

- Two patients in a row to the ER? Never happened before- Didn’t believe this was his heart based on what I knew about him (young, strong, alcoholic) and test results- Also knew he would argue with me about going to the ER

because that’s the type of patient he was

Listening for Clues into the Patient’s Perspective*

Clues per visit Emotional in nature Responded positively to patient emotions

Levinson, et al 2000 JAMA

Surgeons Primary

Care1.9 2.6

60 % 70%

38% 21%

* Visits with missed opportunities tended to be longer

Missed Clues (Empathic Opportunities)

Thoracic surgeons or oncologists responded to 39/384 empathic opportunities (10%)

5 0 % o f t he s e statements occurred in the last one-third of the encounter, whereas patients concerns were evenly raised throughout the encounter.

Conclusion: Too little too lateMorse, et al 2008

The Literature on Self-Assessment in Medicine

Students underestimate their performance in 1st two years (on exams) and overestimate performance in 3rd year (on OSCEs) (Fitzgerald, White & Gruppen, Med. Educ., 2003)

Students in the 3rd year of a PBL curriculum who completed self-assessments before and after an oral exam demonstrated poor accuracy when compared with actual performance (Tousignant & DesMarchais, Adv in Health Sci Educ, 2002)

No relationship between self and instructor assessments in all competency areas for PGY1s (Barnsley, et.al. Med.Educ. 2004)

65% of studies that compare physicians’ self assessment with external observations (gold standard) of their performance show little, no or an inverse relationship (JAMA, 2007)

‘My Test Results’

Medical Student who Excels at Following Protocol

How do we ‘deliver’ feedback around these high level skills?

Focus on Thinking Skills Encourage reflection Engage in perspective-taking Facilitate self-assessment

Focus on Action Plan Goal setting Monitoring

Use Questions to - -

Types of Questions

Asks focused questions

Asks leading questions

Uses open/exploratory questions

Uses open/Reflective questions

TeacherTeacher LearnerLearner

Knowledge Metacognition

Integrating opinion, direction, Integrating opinion, direction, information and information and questioningquestioning to to

deliver feedbackdeliver feedback

The Sexual History

Role of the Teacher

anticipate and reflect gain insight about self and others’ perspectives learn how to learn (lifelong) improve clinical performance

Use effective feedback to help the learner

Teaching Role-Play

‘My Test results’

Case Discussion

and Practice

1.1. GoalGoal: Identify a learning goal and : Identify a learning goal and get agreementget agreement. .

2.2. NeedNeed: Consider what the student says he/she needs. : Consider what the student says he/she needs.

3.3. ObjectivesObjectives: Make them explicit.: Make them explicit.

4.4. MethodsMethods: Encourage the student to offer ideas that : Encourage the student to offer ideas that match learning style and resources. match learning style and resources.

5.5. Re-EvaluateRe-Evaluate: Set a time to re-evaluate. : Set a time to re-evaluate.

** Develop an Action Plan for a role-play case Develop an Action Plan for a role-play case

Action PlanAction Plan**

• To improve performance by using To improve performance by using explicitly explicitly statedstated objectives and strategiesobjectives and strategies. .

• To teach skills that encourage self assessment To teach skills that encourage self assessment and self correction (independence and life and self correction (independence and life long learning).long learning).

Reason for Action PlanReason for Action Plan

The Action Plan:Prioritizing and Insuring continuity

How do you assure student continuity from one interview to the next when time has elapsed?

How do you build on skills? How do you remember what they were

working on? How do they?

The Action Plan:Prioritizing and Insuring continuity

Do the interviews sequentially build skills? Progressively more complex Similar or different tasks How does one set of interviews inform others in

the curriculum? What are you building toward? Complete history A Tool box of skills

Case Discussion