Giving Effective Feedback

to Residents in the
Emergency Department
Patrick Brunett, MD, FACEP
Oregon Health & Science University
Portland, Oregon USA

Acknowledgements
The presenter wishes to acknowledge the contributions of the
following individuals in the preparation of these slides:

Judith Bowen, MD
Esther Choo, MD
Todd Ellingson, MD
Sarah Gaines, MD
Susan Promes, MD
Lalena Yarris, MD

Overview
• Introduction
• Why give feedback?
• Obstacles to effective feedback
• Techniques
• Examples
• Promoting feedback
• One Minute Preceptor

Feedback vs. Evaluation
• Feedback      

Timely
Based on specific observed behaviors
Neutral, information
Level-based
Directed toward the learner
Formative (goal to improve future performance)

Feedback vs. Evaluation • Evaluation       Appraisal of performance over time Directed toward learner and program leadership Scheduled intervals Level-based and competency-based Information and judgment Assesses readiness for advancement .

Core Competencies • Medical knowledge • Patient care • Practice-based learning • Interpersonal and communication skills • Professionalism • Systems-based practice .

even in highly motivated learners .Why give feedback? • Essential to clinical education • Learners want feedback • Required by regulatory bodies (ACGME) • Without feedback  Learning is inefficient  See only minimal improvements.

Barriers to Effective Feedback • “I don’t have time…”     Effective feedback takes little time 30 to 90 seconds Quality. feedback valued by learners Instructors believe effective feedback requires more time than learners (Yarris. et al 2008) . not quantity.

tone. structure . self doubt • Requires proper setting.Barriers to Effective Feedback • Feedback is not recognized by learners  Instructors’ perception of quantity and frequency of feedback provided far greater than learners’ perception of feedback received • Uncomfortable giving negative feedback • No long term contact.

Barriers to Effective Feedback • Feedback is given but ineffective:       “Great job!” “Excellent” “Had a good shift” “Need some improvement” “Hard worker” “Work harder” .

Barriers to Effective Feedback Instructor observe interpret formulate deliver Learner expect receive decode respond .

Techniques • Take a pause from activity • Be friendly. approachable • Make eye contact • Draw out the learner  “How do you think that encounter went?”  “Did you feel comfortable performing that procedure?”  “What is your understanding of this clinical problem?” . supportive.

Techniques • Begin by complimenting good behavior  “I really liked the way you…”  “You seem to be very comfortable with…”  “You did a very nice job with…” .

not criticism • Objectively examine performance with the learner .Techniques • Focus on one or two key points for constructive feedback • Be VERY specific • Explore breadth and depth of learner’s knowledge base • Provide information.

Techniques • Sandwich Technique Positive Constructive Task/Plan Positive Constructive • Chocolate Sundae Technique Positive .

Techniques • Make a plan for improvement  Selected readings. articles. tell me what you found” . lab • Specific follow up  “Come back and we’ll discuss the patient again”  “Once you’ve done X. websites  Reexamination of patient. images.

Techniques • • • • • Give feedback immediately Give feedback often Be brief (30 to 90 seconds) Be concise Do not give a mini lecture .

New Innovations • Shift Cards .Methods of Feedback • Face to face  Most powerful  Most difficult • Email comments • Electronic residency management system  E*Value.

Methods of Feedback .

Methods of Feedback .

Methods of Feedback .

Methods of Feedback .

ucsf.edu/Resource/Feedback MovieFinal.emresidency.html .Promoting Feedback • Faculty Development courses • Support from department leadership • Teach residents to ask for and expect feedback • On line resources: http://www.

One Minute Preceptor Model • Initially described by Neher et al 1992 • Fosters learner “ownership” • Identifies knowledge gaps • Focuses learning issues .

One Minute Preceptor Model Teaching the One Minute Preceptor (Furney et al) •Randomized controlled trial •28 residents received a 1-hour session vs. 29 residents in control group •Taught students using OMP model •Easy to learn and implement •Satisfaction for both the teachers and the learners .

One Minute Preceptor Model • Five Microskills      #1 Get a commitment #2 Probe for supporting evidence #3 Teach general rules #4 Reinforce what was right #5 Correct mistakes .

Get a Commitment •Gives learner sense of responsibility for patient care •Determine how the learner views the case .

Get a Commitment  “What do you think is going on?”  “Why do you think the patient has not been taking their medications?”  “What is the next step you would like to do in the work-up?” .

Get a Commitment • Ineffective technique:  “I think this sounds like a MI. don’t you agree?”  “Anything else?”  “I think you are way off” .

Probe for Supporting Evidence • The preceptor is diagnosing the learner • Probing their     Knowledge base Understanding of situation Ability to reason Attitudes and biases .

Probe for Supporting Evidence  “What has made you think that this is pneumonia?”  “What else did you consider?”  “Why do you think this is not a dissection?”  “What are the major findings in this case that led you to that conclusion?” .

”  “Guess what I am thinking…” ..Probe for Supporting Evidence • Bad Examples:  “Don’t you have any other ideas?”  “This is obviously a classic case of….

Teach General Rules  Focus on specific competencies relevant to this particular learner  Check for learner understanding of what you are discussing  Helps to generalize to future cases .

Teach General Rules  “If the patient has pneumonia and is hypoxic.”  “Antibiotics should be started in the ED but will not help fix their initial hypoxia.” . oxygen should be started immediately.

Teach General Rules • Bad Examples:  “This patient is in heart failure and needs a diuretic”  “Don’t start the beta blocker now”  “I always give antibiotics to this type of patient” .

Reinforce What Was Done Right • Be specific with what was done well • Explain why their performance was good • Give specific praise .

” . That was excellent and helps ensure the patient’s safety. You earned their trust.Reinforce What They Did Right Examples  “You considered the patient’s allergy history when you chose that antibiotic.”  “You were very sensitive to the emotional needs of the family.

Reinforce…bad example • More Bad Examples:  “Great job!” (with what…?)  “That was the right treatment” (explain why) .

 Uncorrected errors will be repeated.Correct Mistakes  Teach the learner how to avoid repeating the same error in the future. .

”  “The incidence of drug resistance to that antibiotic is high.Correct Mistakes  “I understand the patient has had multiple visits to our Emergency Department.” . However. therefore another should be considered. we still need to do a thorough H&P and treat their pain.

Correct Mistakes • “YOU DID WHAT!?!” .

Common Teaching Errors • Taking over the case • Not waiting long enough to listen • Lecturing the learner • Asking questions that lead too much • Asking questions that are too vague • Pushing learner too hard .

staff • Balancing teaching and clinical tasks . students.Unique Challenges to Teaching in the Emergency Department • Shift work • Rapid pace • Hectic environment • Variety of patients.

General Teaching Principles  Best done in real-time  You are constantly modeling behavior for students and residents  Consider bringing the OMP to the bedside  Teaching takes time  Every case has a teaching point .

Thank you for your attention Questions? Patrick Brunett. Oregon USA . MD. FACEP Oregon Health & Science University Portland.