The trainee in difficulty: Breaking the bad news

1. The trainee in difficulty:Breaking the bad news Dr Val Bythell Programme director Northern Schools/ Northern Deanerty

2. Whose ‘bad’ is it anyway? • Yours • Others • The trainee’s...

6. All feedback is ‘good’ • Feedback that is thought / intended to be ‘good’ may not be perceived as such by the trainee if poorly given • Negative feedback may bring out into the open longstanding difficulties that the trainee is aware of and wants help with • ‘Feedback is the breakfast of champions’

7. Why is the trainee in difficulty? Trainees don’t want to perform poorly…. • Sickness • Social circumstances • Inadequate training • Lacking ability

8. Inadequate training Not intentional.. • Failure of timely feedback is extremely common

9. What inhibits feedback? • Failure to observe • Fear of - emotional response - reduction of teacher’s popularity - harm to student’s self-image Often justified as ‘the circumstances aren’t appropriate’, ‘I don’t have time’ or ‘its not my job’

10. Consequences of inadequate feedback • Trainee is ‘adrift’, without direction • More susceptible to negative body language • May develop false standards, arrogance • May develop paralysis, fear • Becomes dependent on summative feedback, exams • Loses opportunity to improve (eg moves to another post)

12. What type of information do you have? • Hearsay / gossip • Direct report - verbal,written • Directly observed performance • Concrete outcome data • Sickness / absence data • Trainee’s self-reported difficulties

13. What do you need to do? • Consider risk management / patient safety issues • Obtain as much specific information about the perceived difficulties, and about perceived good behaviour, as possible • Arrange a feedback / appraisal meeting with the trainee ASAP - appropriate setting etc

14. Effective feedback - ‘Do’s’ • Prepare • Maintain respect, empathy • Begin with open questions • Listen • Limit feedback to remediable behaviour • Be specific about both ‘good’ and ‘bad’ behaviour • Check understanding

15. Remediable behaviour vs. inferred... ‘You are often late for lists’ is better than ‘Your time-keeping is poor’ ‘I have some difficulty in understanding what you are saying’ is better than ‘You don’t communicate well’

16. Possible causes of frequently being late... • Not adequately informed re. time to attend • long/difficult journey • caring for dependents • illness - eg drug dependency, depression • awareness that things are going badly • etc etc

17. Giving feedback • Ask the trainee to tell you how things are going first What is going well with your training? What aspects could you improve?

18. Effective feedback - ‘Don’ts’ • Don’t use indirect / inferred statements • Don’t let fear prevent you from giving negative feedback • Don’t be generally supportive then specifically critical • Don’t discuss innate characteristics or attitudes, only actions

19. Receiving feedback • Listen • Check understanding • Try not to be defensive • Thank the giver for the feedback

20. If the feedback is not skillfully given & received... • Defensive behaviour - ‘shoot the messenger’, • Blames others and circumstances • Basic message is not heard

21. If feedback is successfully given... Together with the trainee (and others) • Formulate goals/objectives • Decide on how best to achieve those goals

22. In summary Don’t avoid giving ‘negative’ feedback Always give specific positive feedback first Comment on behaviour, not core characteristics It will not be as bad as you think it will!

23. Thank you Feedback in clinical medical education. J Ende JAMA 1983;250:777-781 http://www.ncl.ac.uk/nsa