Hi, I am Julie Damp. We are going to talk about effective feedback, both what it is and how to incorporate it into a training program. Our learning objectives for this module are to understand the importance of feedback in competency-based medical education, to review key characteristics of effective feedback, and to discuss ways to incorporate feedback into a training program, both for trainees and for faculty. First, let's define feedback. Feedback is informed, objective information on performance that is intended to guide future performance. As in any system, clinical performance can be impacted by a feedback loop. Effective feedback improves learner performance and therefore should improve patient care. It is a critical part of learning and addresses aspects of performance that cannot be measured on standardized testing. It lets the learner know that you are invested in their progress and development. Without feedback, a learner may be uncertain or become overconfident. They may assume that since all went well, that this equals competency, or they may learn by trial and error. Feedback can be given in multiple areas, including knowledge, such as knowledge of medical facts or clinical reasoning, skills, such as procedural skills, attitude, such as ethics and professionalism, and behavior, such as communication. It is important to understand that feedback can be given and impact performance in all of these areas. Faculty have commonly cited barriers to giving feedback. Faculty may not feel they've spent enough time with a trainee to be able to give them feedback. They may be concerned about offending the trainee or creating conflict. Faculty may feel that it is not going to change behavior or that it takes too much time. And finally, faculty frequently feel untrained in how to give effective feedback. Addressing these barriers for faculty can help increase the amount of feedback they give, as well as the quality of the feedback. Let's talk about what effective feedback looks like. It should be given in a timely fashion, in close proximity to the performance on which it is based. It should be expected and labeled. For example, by statements such as, I would like to give you some feedback, or let's schedule a time today for feedback. Feedback should always be formative rather than summative. This means that it is meant to inform and guide improvement rather than sum up performance at the end of an experience or evaluate the learner. Feedback should be based on objective, observable performance. It should be nonjudgmental and be specific. For example, your evaluation of Mrs. J was thorough and your accurate physical exam helped us catch her ruptured papillary muscle is much more specific, objective, than good job on that case. Effective feedback should be based on the learning objectives and assessment standards for a particular experience and rotation rather than individual expectations. As adult learners, our trainees will be most receptive to feedback when they have buy-in or insight into the area for improvement. This is one of the reasons why asking them to self-assess is critical in giving effective feedback. Effective feedback becomes part of the culture and is incorporated into everyday activities. It should also be a conversation, bi-directional, between faculty and trainee and trainee and faculty. Now let's talk about a model for giving effective feedback. First, it's important to prepare yourself and the learner for feedback. Make sure the setting and timing are appropriate. Make sure you know the standards by which you are assessing learner performance. Second, ask the learner for an assessment of the performance and ask them clarifying questions if you need to. For example, rather than stating, it took you a long time to engage the RCA in that case, asking, what did you think about your approach to engaging the RCA in that case, will encourage reflection and buy-in from the learner. After the self-assessment, provide your specific assessment to the learner, including both positives that should be reinforced and areas for improvement. The next step is to ask a learner to make a plan for improvement. You can provide guidance to them as you need to. The plan should lead to a summary of what you discussed and a plan for follow-up to make sure the learner has improved. Depending on the setting of the feedback, this may be follow-up with you, with another faculty, or for the learner on their own. A simple way to remember this model is the three steps of ask, tell, ask. Ask the learner for self-assessment. Tell the learner your assessment. Ask the learner for a plan for improvement. Let's look at some examples. A more effective way to say excellent presentation would be to say your presentation was complete with an appropriately targeted physical exam. This is more objective and specific, providing the learner with more meaningful information. A more effective way of saying you need to make sure the patient understands what you are telling them would be to say, I notice you use quite a bit of medical terminology. Do you have thoughts on how to make sure the patient has understood what you are telling them? This is more objective and encourages self-reflection on the issue as well as on a plan for improvement. More effective than, you tend to be disorganized, would be, tell me about your system for keeping track of patients. This encourages self-reflection, making the learner more receptive to the feedback. More effective than, it took you too long to perform that procedure, would be, it looked like you may have had some difficulty engaging the RCA in that case. Tell me about your approach. This is less judgmental and again encourages self-reflection, which helps the learner buy into the improvement rather than feeling embarrassed or defensive. Now that we have talked about how to give effective feedback, how can you address the barriers we discussed earlier with your faculty? As we have seen, feedback can be given after any amount of time that a faculty has been able to observe specific performance of a trainee. So, after a single procedure, after a day in clinic or a day on rounds, or after a week on a rotation together. When given correctly, feedback shows concern for learner development and works with the learner to improve rather than being criticism or being offensive. Knowing how to give effective feedback will increase the likelihood that the learner buys in and is enabled to complete a meaningful plan for improvement. When feedback is targeted appropriately in practice, it does not need to take much time and can be done in just a matter of minutes. Providing your faculty with training on how to give effective feedback will increase the frequency with which they do this and the quality of the feedback they give. Here are some thoughts to help address these barriers with faculty in your own program. Give your faculty their performance information based on evaluations from trainees. Reinforce and repeat frequently the importance of giving effective feedback for your trainees. Review this module with them. You can do this within a conference or faculty meeting or send to individual faculty for review. Lead a discussion on the topic within a faculty meeting or a conference. Have faculty role play with case-based scenarios in order to practice giving effective feedback. Have a local expert come to give a grand rounds or workshop on giving effective feedback. How are you providing faculty with feedback on their teaching? You can send faculty their teaching evaluations from residents and fellows to review. This can be done with individual evaluations or with a compilation of evaluations over several months up to a year. You can meet with faculty to review evaluations and have them self-assess and create a plan for improvement when needed. Encourage your faculty to ask trainees they are working with to provide them feedback on their teaching. And always remember that as program director you can control which faculty serve on teaching services. Trainees often report that they do not get enough feedback. In addition to providing your faculty with tools with which to give this, you can also help your fellows be receptive to feedback. Encourage them to ask faculty for feedback frequently. Remind them that this is an active process and they should work to avoid defenses in being receptive to feedback, such as disparaging a particular source or attributing the feedback to style differences. Review evaluations and isolated reports on performance with them, both when given on strengths and when given on areas for improvement. Finally, teach your fellows how to give effective feedback to their learners. This will help them be more comfortable with the process as well as help incorporate it into the local culture. Effective feedback is a critical part of learning and a key to the success of our trainees. I hope this helps you in your own program as you incorporate effective feedback for your fellows and faculty.

Julie Damp

feedback

medical education

learner performance

patient care