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The trainee in difficulty: Breaking the bad news. Dr Val Bythell Programme director Northern Schools/ Northern Deanerty. Whose ‘bad’ is it anyway?. Yours Others The trainee’s. All feedback is ‘good’.

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The trainee in difficulty breaking the bad news l.jpg

The trainee in difficulty:Breaking the bad news

Dr Val Bythell

Programme director

Northern Schools/

Northern Deanerty

Whose bad is it anyway l.jpg
Whose ‘bad’ is it anyway?

  • Yours

  • Others

  • The trainee’s...

All feedback is good l.jpg
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’

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Why is the trainee in difficulty?

Trainees don’t want to perform poorly….

  • Sickness

  • Social circumstances

  • Inadequate training

  • Lacking ability

Inadequate training l.jpg
Inadequate training

Not intentional..

  • Failure of timely feedback is extremely common

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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’

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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)

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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

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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

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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

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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’

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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

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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?

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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

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Receiving feedback

  • Listen

  • Check understanding

  • Try not to be defensive

  • Thank the giver for the feedback

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If the feedback is not skillfully given & received...

  • Defensive behaviour - ‘shoot the messenger’,

  • Blames others and circumstances

  • Basic message is not heard

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If feedback is successfully given...

Together with the trainee (and others)

  • Formulate goals/objectives

  • Decide on how best to achieve those goals

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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!

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Thank you

Feedback in clinical medical education. J Ende

JAMA 1983;250:777-781