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A Donkey ’ s Tail Feedback Webinar 2013. Shannon Waterman, MD Swedish Family Medicine Cherry Hill Seattle, Washington. Objectives. What is feedback? Examples of effective feedback Ask-Tell-Ask (think sandwiches…) Skills practice and cases

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a donkey s tail feedback webinar 2013

A Donkey’s TailFeedback Webinar 2013

Shannon Waterman, MD

Swedish Family Medicine Cherry Hill

Seattle, Washington

  • What is feedback?
  • Examples of effective feedback
  • Ask-Tell-Ask (think sandwiches…)
  • Skills practice and cases
  • TED: Brené Brown’s “The Power of Vulnerability”
feedback is not evaluation
Feedback Is Not Evaluation

What words of feedback might he need?

What evaluation might he get?

Is generic praise helpful?


Pause for poll

Realms of feedback

feedback vs evaluation
Feedback vs. Evaluation




Looks toward the future


Red ink in the margin


Reviews recent past

All-Star Voting

Final grade


Pause for poll

Your experience?

elements of effective feedback
Elements of Effective Feedback

1. Expected, timely and routine

2. Based on first-hand information

3. Descriptive rather than evaluative

4. Focused on issues learner can control

5. Specific and concise

6. Private

7. Reciprocated

Ende J. Feedback in Medical Education. JAMA. 1983

barriers to feedback
Barriers to feedback
  • Vulnerability (want to be liked, avoid conflict)
  • Poor observers, unable to “unpack” our observations
  • Limited time
  • Different capabilities of learners at different levels
  • Myth (generational?)
    • Adult learners do not need feedback.
    • “I never got any feedback, so why should you?”
how good are we
How good are we?
  • Surgery
    • 86.2% attendings felt feedback given “often/always” after incident vs 12.5% residents
    • 85.7% attendings felt feedback on specifics

vs 54.2% of residents

    • 96.6% attendings felt feedback started with positives

vs 54% of residents

    • 69% attendings felt they gave “complete” feedback

vs 16.7% of residents

Liberman et al. Surgery residents and attending surgeons have different perceptions of feedback. Medical Teacher. 2005:27(5), 470-72

Thanks to Uniformed Services University, Jessica T Servey, Lt Col, USAF, MC. Director, Family Medicine Clerkship

how good are we1
How good are we?
  • Internal Medicine
    • 8% residents “very satisfied” with feedback
    • 80% stated “never” or “infrequently” received corrective feedback
  • Family Medicine
    • Inpatient feedback only 14% of comments specifically targeted
  • Emergency Medicine
    • Attendings more satisfied with timeliness and content than residents
    • Attendings rate as constructive more often than residents

Sostok M, Coberly L, Rowan G. Feedback Process between Faculty and Students. Acad Med. 2002;77(3), 267.

how good are we2
How good are we?
  • MSIII students, Internal Med rotation at Ohio VA
  • 1 hour bedside history & physical observed (58 sets)
  • Feedback given, questionnaire completed
    • Perception of time spent on feedback similar (26 minutes)
    • Number of items covered: 3.3 by faculty report and

2.7 by student report

    • Only 34% agreement in content of the feedback

Sostok M, Coberly L, Rowan G. Feedback Process between Faculty and Students. Acad Med. 2002;77(3), 267.

abridged history of feedback
Abridged history of feedback

The Old Feedback Sandwich

The New Feedback Sandwich

Praise / Criticism / Praise

Ask / Tell / Ask

ask tell ask
Ask - Tell - Ask
  • Ask learner to assess own performance.
    • Have you seen a patient like this before?
    • What went well?
    • What couldhave gone better?
cases why ask
Cases – Why “Ask”?
  • Reflecting on encounters in medicine can deepen our satisfaction and engagement with what we are doing.
  • It can help us recognize the profundity of what we do.
  • Developing your ability to reflect may decrease burnout.
ask tell ask1
Ask - Tell - Ask
  • Tell what you observed
    • React to the learner’s observation
      • Feedback on self-assessment
    • Include both affirmative and corrective elements
      • “I observed….”
    • Give reasons in the context of well-defined shared goals
      • “You want to become more skilled with cervical exams...”
ask tell ask2
Ask - Tell - Ask
  • Ask about learner’s understanding. “Teach-back.”
  • Explore strategies for improvement.
    • “What could you do differently?”
  • Replay relevant part of encounter
    • “Show me how you might phrase…”
general strategies
General Strategies
  • Reinforce positive behavior – catch them doing something right
    • “I appreciated how you incorporated the family into your presentation this morning.”
  • Redirect negative behaviors
    • “I’d like to give you feedback on your presentation. When there is a family present on rounds, be sure to start with an introduction of the team.”
feedback be specific
Feedback: Be specific
  • Vague: “You seem bored on rounds.”
  • Specific: “Sometimes you leave the room before we finish discussing a case. I think it is important for all of us to hear about other cases for education and cross-cover.”
  • Vague: “You seem disorganized.”
  • Specific: “On work rounds it might be more efficient to see all the patients, then write orders, review x-rays and then talk to consultants.”
feedback be specific1
Feedback: Be Specific
  • Vague: “Be more careful with the reflex hammer.”
  • Specific: “What did you learn from your exam?

Here, let me demonstrate how I do the reflex exam and I think you’ll be able to pick up more subtle differences.

Does that seem like a technique you could use with your next patient?”

feedback be descriptive
Feedback: Be Descriptive
  • Vague: “You relate well to patients.”
  • Specific: “How did that go for you?

When you asked who would care for her dog when she is admitted for surgery, I saw her visibly relax. Your caring insight helped change the whole tone of the conversation.

Did you notice that change in her affect? Was that a natural thing for you to do?”

environment provides feedback
Environment provides feedback
  • Patient and patient’s family
  • Peers (student, residents)
  • Staff and consultants
  • Own personal perception*
why learners don t hear feedback
Why learners don’t “hear” feedback?
  • Receiver doesn’t:
      • Recognize feedback when it is given
      • Understand the message
      • Reflect on the meaning
  • Giver:
    • Doesn’t make time to give feedback
    • Gives feedback in public setting (shaming, humiliating)
    • Vague examples
  • Interplay between giver/receiver:
    • Heard and taken as personal criticism…personality or style conflict…distrust based on gender/culture
take performance to the next level
“Take performance to the next level”
  • Tell them what they’re doing right (they may have done it on accident!)
  • Positive, reinforcing feedback can be followed with restating new goals to reach a new level.
  • For any student or resident, the end of one rotation is the start of the next. Help them define their next goals.
red flags take action
Red Flags – Take Action!
  • Behavior that is unsafe, unethical, unprofessional should be addressed immediately.
  • Discuss with learner promptly and privately.
  • Notify attending. “No Surprises” policy.
  • Note learner’s progress and improvement. Comment on this in evaluation, if appropriate.
  • What is feedback?
  • Examples of effective feedback
  • Ask-Tell-Ask (think sandwiches…)
  • Skills practice and cases
  • TED: Brené Brown’s “The Power of Vulnerability”
cases resident inpatient service
Cases – Resident inpatient service
  • You sit down with the intern for a feedback session at the end of your inpatient week.
  • You begin with some of the things she has done well, then turn to the areas she needs to work. Team feedback (and evaluation) suggests she is performing at a solidly average level.
  • You bring up several patients whose past medical history she had not investigated adequately and comment that she needs to be more succinct in her write-ups.
cases giving student feedback
Cases – Giving student feedback
  • The resident gets angry. “There is never anytime for me to see the patients.” She considered it great time management and commitment on her part that she would wake patients up at 4am to get a more complete history.
  • She also feels that you have not helped her or understood that she was taught to “write long notes for the attending.”
cases giving student feedback1
Cases – Giving student feedback
  • What went wrong? How could you have made this a more effective evaluation session?
  • “ You need to continue working on your efficiency. You improved substantially by keeping a list and learning to prioritize better, but you still need to work on shortening your notes.”
    • Is this good feedback?
    • Is this effective feedback?