Few opportunities exist in medical training, and particularly in medical practice, for physicians to get feedback on interactions with patients. Even when working in teams, the interaction with the patient is rarely observed by peers or mentors. Feedback becomes a critical part of skill practice sessions, as these sessions provide an opportunity to hear from peers, faculty, and sometimes the patients themselves, how the patient interaction went.
While one goal of skill practice teaching is to help the learner develop self-assessment skills, giving feedback based on external observations can help the learner calibrate her own sense of her strengths and limitations.
- Learners often focus on their limitations, not aware of their strengths or what it is that they already do that is effective. Giving specific positive feedback reinforces things the learner is doing well.
- Without being videotaped or observed, it is difficult to know how one's body language, affect, or tone comes across to others. Providing feedback in these areas can help a learner move forward, as they can say the 'right' things but if mismatched with body language, the effectiveness of the communication skills will be limited.
- It takes effort to give specific, constructive feedback. Targeting concrete behaviors takes careful observation. Often feedback is too general ("good job").
- Many of us have not had good role models for giving constructive feedback. It is more comfortable for us to stay in the realm of positive feedback without addressing areas that might need work.
- Alternatively, many of us assume that the positive behaviors do not need to be discussed. We miss an opportunity to reinforce what someone has done well.
- Learners can only absorb a certain amount of feedback. Giving some specific feedback while not overwhelming them is a difficult balance to strike.
Be specific. The most effective feedback is specific. Faculty can take notes during the patient encounter to capture specific phrases that the learner used that were particularly effective. Often learners will not remember what they said, or be conscious of the skills they are employing instinctively. Reinforcing the skills helps to bring them into conscious practice. In the exchange below, the faculty used the group to help the learner identify specific behaviors she was using that helped the conversation go smoothly. He starts by checking in with the learner and closes by offering his own observations and feedback.
- FACULTY: So, let's stop for a minute and talk about how's it going before now. How's it going?
- LEARNER: I think it's going well. The patient's comfortable, he's makes me feel comfortable, we're on the same page, he doesn't want any more chemotherapy.
- FACULTY: So what are the things that you are doing that get you all that information that make it easier. What is she doing? [Turns to the group participants]
- [4 Participants respond with feedback]
- FACULTY: I liked how you initiated the interview. You said, "I gave you a lot of information last time. Before we start I want to see what your questions and concerns are." so you started off very clear, you were organized, you said ...'let's check in' at the very beginning. And then all the follow up questions were based on what he said. So he said something, you summarized and went further. It was like a dance and you were right in step.
Tie Feedback to Learner Goals. If you have done the work of goal-setting at the outset, you have asked the learner for particular areas where he would like feedback. It is important to close the loop and given him feedback about how he did with those goals.
- FACULTY: You've done some great things. You asked specifically about talking too much? You didn't. You did a really nice job. All the information you are giving has been in really tiny chunks; just little pieces and then getting his reaction. So, the thing that you were concerned about you are doing really well.
In another exchange, faculty helps to problem-solve with the learner and extends the learner's goal to address the challenge that has come up in the encounter. Not all feedback needs to come at the end by way of summary statements. Giving feedback in the middle of a skill practice session can be very useful for helping the learner continue to work at his learning edge.
- FACULTY: Timeout. How do you feel about the way things are going?
- LEARNER: I think I am sort of wandering. I don't think I am staying on track.
- FACULTY: Give me an example of where you feel you were wandering.
- LEARNER: Well, when he was going on and on about family and all of that stuff I wasn't quite sure whether to go in that direction or where to go. So I'm not sure that I was really focused…[Learner continues and group discussion occurs]
- FACULTY: I know you said before that you wanted to follow his lead. And he was sort of bringing up all sorts of things -
- LEARNER: - I wasn't sure where to go first. I was overwhelmed.
- FACULTY: What I am hearing is that you wanted to follow him, but there was all this different stuff, and you couldn't prioritize - there was so much. So maybe what you could have done is ask him to prioritize it for you: "It sounds like this news is bringing up all sorts of things. What do you feel - if you can prioritize now - are your greatest concerns?" Do you want to try that?
- LEARNER: Okay, sure.
Tie Feedback to Behaviors. Feedback should also be tied to specific learner behaviors. What did he do, and what might he do differently? Sometimes a group member can give feedback that is not tied to a behavior, such as, "I think the patient was really confused by what you were saying." Faculty can work to reframe the feedback into something that the participant observed or heard, and what was said or done by the learner, e.g. "When you said 'Phase I trial' the patient seemed to sit back and her eyes kind of glazed over for a second. What do you think Phase I trial meant to her? What would you like to be conveying to her right now?" Faculty can also frame their request for feedback in very specific ways to encourage more specific feedback, e.g. "Well, let's get some feedback, Okay? I'm curious what do people think about what has gone on so far? What did you observe?.
The Feedback Sandwich. Much has been made about the "feedback sandwich" in medical education. The expectation is that you should frame your negative comments with two positive comments to be more palatable for the learner. There are strengths and weaknesses to this approach. Taking the best of what is intended might be the workable strategy for you.
We agree that learners should get feedback on both things that they are doing well and things that they might do differently. Starting with positive feedback can enhance a learner's sense of safety. A limitation of positive feedback in the sandwich is that if the learner has been socialized to the approach, they often say they cannot hear any of the positive feedback because they are waiting for the other shoe to drop. You can get around this by emphasizing with the learner that there were specific things that she was doing that were really effective. You want to point them out to assure that she will do them again in the future.
The issue with negative, or "constructive", feedback is that we do not have many role models for doing this well. Negative feedback can come across as tough criticism, or more often, can just get skipped because it is uncomfortable for both faculty and learner. Modeling giving and receiving feedback about areas to work on can help set the tone and expectation that there will be an open exchange of feedback with you. Making it part of the routine of what you give learners and what you ask for from them means that no one is singled out. Everyone has areas that they would like to continue working on. Playing to learner strengths is one of our strategies that we emphasize. You can frame feedback in terms of skills they could use more often (e.g. "You did a great job with your first empathic comment to the patient. I think if you kept doing more of that throughout the interview, she would have felt even more connected with you.")
This strategy also works with a whole small group (e.g. "One thing you guys are doing well is exploring. Maybe what you want to focus on is simply making empathic statements - acknowledging, legitimizing emotions first, before trying to take it to the next step to learn more about it").
- Feedback is the primary way to reinforce learning.
- Feedback can come from faculty, other group members, or the patients themselves.
- Emphasize specific behaviors learners are doing well.
- Work at the learning edge with learners by helping them to problem solve the places where they get stuck in the interview. By giving feedback about what you observed about the difficulty, the learner can often generate ideas about what to do differently.
- Ende J. Feedback in clinical medical education. JAMA. 1983; 250:777
- Kurtz S, Silverman J, Draper J. "Running a Session: Analysis and Feedback in Experiential Teaching Sessions," Chapter 5 in Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press, 1998.