Lisa MacLean, MD
Asst. Dean of Student Affairs
Wayne State University School of Medicine

• Review of the literature
• Discuss the challenges of generational differences
• Define feedback and the barriers to providing effective feedback
• Introduce the Feedback Triad
• Describe giving, receiving, and soliciting feedback in more detail
• Challenging Cases
• Quick Post-test
• References

• Trainees WANT feedback
• A study of 1500 residents found that 96% believed that feedback from an instructor was important for learning.
• Trainees believe that they never get enough feedback.
• Giving high-quality feedback is positively correlated with teaching ratings.
• Constructive and specific feedback can improve learner knowledge and skills.
• Written and oral feedback are equally acceptable and effective. Videotape review is not better than oral feedback alone.
• Giving/receiving feedback is a life long skill that can be learned.

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Boehler, et al. 2006 An investigation of medical student reactions to feedback: a randomized controlled trial.
• The following study was designed to evaluate the impact of feedback on student procedural skills:
• Study Group: 33 second- and third-year medical students, all given specific instruction in 2-handed knot tying.
• Methods: randomized to specific feedback on their skills or general positive compliments; videotaped performing the procedure before and after receiving specific feedback or general comments
• Measurements: Student performance was scored by three blinded observers; student satisfaction with instruction was assessed on a 7point global rating scale.

15
10
5
0
25
Mean Performance Scores
P<0.001
P=0.2
20
Pre-test
Post-test
Specific Feedback General Compliments
Total Possible Ratings 0-32; IRR >0.8
• Specific feedback improves performance of the task
• General comments DO NOT improve performance of the task

Mean Satisfaction Scores
6.2
6
5.8
5.6
5.4
5.2
5
P=0.005
Specific Feedback
General Compliments
4.8
4.6
4.4
7-Point Likert Scale (1=Very Poor; 7= Truly Exceptional)
• Key points:
• Students prefer general compliments to specific constructive feedback

• Specific feedback can improve performance on procedural skills: Feedback

Learning
• Satisfaction with feedback does not correlate with the quality of the feedback: Satisfaction

Quality
• Combination of specific feedback and general compliments may be the best form of instructional feedback.
But you’re not here to learn how to give compliments……

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*****(above dates vary depending on research source)*****

Baby Boomers
1946-1965
41% of Workforce
• Optimistic
• Team oriented
• Interested in health and wellness
• Always learning
•Workaholics
• Like relationships in the workplace and very loyal
• Open minded
• Prefer face to face communication
• Espouse value of “inclusive” leadership
• Focus in workplace on process and output
• Job status and symbols important
• Like knowing their manager and knows and cares for them personally
Gen X’ers
1966-1982
29.5% of Workforce
• Self-reliant and educated
• Latchkey children
• Balance in work and family
• Like to have fun at work
• Like variety
• Technologically savvy
• Approaches authority casually
• Can be skeptical
• Require minimal supervision
• Prefers flexible work hours and informal work environment
• Grew up with computers
• Started 80% of new businesses in the last 3 years
•Focus in the workplace on relationships and outcomes
Generation Y/Millennials
1983 →
22.5% of Workforce
• Optimistic and sociable
• Confident/Trophy kids
• Diverse and political
• Goal setting is a priority, high performers
• Can-do attitude
• Want work life balance
• Technological savvy
• Know what they want and are used to getting it so can come across as entitled
• Search for co-worker with the same high ideals they have
• Can be high maintenance
• More likely to question and have limited experience with genuine feedback
• Have a deep desire to make the world a better place

“When you don’t call me into your office, I must be doing a good job.”
“I must be doing okay because there haven’t been any speeches about patient safety lately.”
“I must be doing okay because you always tell me when I make too many errors.”
“When you don’t send my reports back, I know I’m doing a good job.”
“When you don’t look at me and shake your head, I know
I’m doing a good job.”

• Specific information provided by another source with the intent to improve performance or understanding
• The art of observation (of actions) and description (of outcomes)

• INTENTION: to narrow the gap between actual and desired performance
• PURPOSE: to encourage learners to think about their performance and how they might improve. Ultimately to improve learning and teaching!
• GOAL: to help learners reconstruct knowledge, change performance and feel motivated for future learning.

• Good practice is not reinforced
• Poor performance is not corrected
• The path to improvement is not identified
• Learners assume all is well
• Learners have to guess their level of competence
• Learners may have to learn by trial and error at the patients expense

• Receiving feedback that is too general
• Receiving feedback on areas unrelated to a student's specific learning goals
• Receiving constructive criticism but no suggestions for improvement (action plan)
• Receiving positive reinforcement without constructive criticism

• Learners always say they want more feedback.
• While learners value feedback, they may not ask for it, recognize it or remember having received it.
• Studies show that faculty and learners did not agree on the number of feedback items given.
• Only 34% of faculty and learners agree on what was said
Schultz et al, Torre et. Al, Sostek

• Can be difficult and awkward
• Received little or no instruction on how to give feedback
• Don't have the resources to correct the problem
• Fear damaging the relationship
• Fear would cause low self-esteem
• Don't want to appear too critical
• Inconsistent feedback from a variety of sources
• Feel like you do not have time

• Learners lack of acceptance of feedback
• A fear of doing more harm than good
• Trainee being resistant or defensive
• A lack of respect for the source of the feedback
• The learner's readiness to respond
• Learners might be reluctant to ask for feedback
• Teachers don't know what to say or how to translate what they see into specific and constructive feedback

“Everyone is afraid to give constructive criticism and instead says “good job” all the time. Even though I’m aware of how UN helpful that is, I find myself following suit.”
Resident RAE Survey 2010

Giving Feedback
“Justification” “Lip service”
Soliciting
Feedback
“Demotivation”
Receiving
Feedback

• Have you communicated your expectations?
• Have you asked how the learner wants to get feedback?
• Have you conducted an orientation?
• Have you probed learner’s knowledge, skills, and abilities?
• Have you checked learner’s experience?

• There are 3 steps to giving effective feedback:
• Laying the Groundwork
• Setting the Stage - establish an appropriate interpersonal climate
• Delivering the Feedback

• Establish mutually agreed upon goals and work as allies
• Clarify your expectations and those of the team
• A normal everyday component of the teacherstudent relationship and therefore expected
• Be clear that you are giving feedback
• Be well-timed identifying when and how the feedback will be given
• Ask the learner how they would like the feedback

• Organize thoughts and observations before speaking
• Select the right place:
• Positive, directed feedback can occur almost anywhere
• Negative feedback should ALWAYS be given in private and without interruption – “fire a warning shot”
• Select the right time:
• Close in time to the episode
• Watch for learners verbal and nonverbal reactions
• The learner must be mentally and emotionally available for the feedback
• Not distraught
• Not exhausted (i.e. post-call)
• Not distracted (i.e. being paged, needed elsewhere)

It was my teacher's genius, her quick sympathy, her loving tact which made the first years of my education so beautiful. It was because she seized the right moment to impart knowledge that made it so pleasant and acceptable to me. −Helen Keller

• Relate feedback to the learner agenda not the teachers
• Elicit the learners thoughts/feelings (focused self-assessment!)
• Reflect on specific observed behaviors not ones interpretation of the students motives/personality
• Be descriptive, nonjudgmental and balanced
• Give in small quantities (2-4) and limited to remediable behavior
• Allow the learner to try again
• Allow the student to offer ideas for improvement
• Summarize and express support
• Develop joint action plan
• Follow up
Ende et. al

• Where am I going? (What are the goals?)
• How am I going? ( What progress is being made toward the goal?)
• Where to next? (What activities need to be undertaken to make better progress?)
• An ideal learning environment occurs when both teachers and students seek to answer each of these questions.

• Set a good foundation
• Teaching, expectations, orientation
• Focus the feedback
• Learner self-assessment
• Describe what you saw
• Going forward
Where am I going?
How am I doing?
Where to next?

• Don't give feedback when you are angry
• Don't give feedback when the other person is not ready for it
• Avoid words of judgment such as "good', "bad",
"should""must", "always", "never" and "sometimes"
• Focus on the behavior that can be changed rather than the person
• Reflect back what the resident is saying…
• Only give feedback with a positive intent of helping the person to whom you are giving it.

• Useful:
• The trainee consistently performed well-focused, logically sequence interviews
• The trainee failed to ask key information to delineate the chief complaint
• Unproductive:
• The trainee did not do as well as other learners in her group
• I don’t believe the trainee belongs on the consult service

• Useful:
• The trainee’s verbal presentations were clear, concise and accurate
• The trainee frequently included unnecessary information/commentary during daily rounds
• Unproductive:
• The trainee seemed to have trouble expressing himself but this is probably due to cultural differences.
• The trainee is a real star

• Useful:
• The trainee was empathic and concerned about all of her patients
• The trainee frequently arrived late and was unprepared for rounds
• Unproductive:
• The trainee needs to be more aggressive
• The trainee was hard working and deserves an “A”

• Listen actively and make eye contact with the speaker
• Understand your own needs and insecurities
• Ask probing questions to make sure you understand what is being said.
• Don't get emotional
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• Breathe deeply and sit back.
Adopt a relaxed body posture and don’t interrupt
• Lower your voice and speak slowly.
• Don't get defensive

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Understand the other person’s perspective before presenting your side of the story
Ask for more details on points you don’t agree with
Accept the input even when you don’t agree with all of it, there will be some good ideas
Show respect for the other person’s perspective.
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Work to improve
Don’t put the burden of solutions to the other person
• Offer ideas of your own
• Seek examples of the behavior at issue to help you understand

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Receiver
Request feedback early
Highlight exactly what you are looking for
Choose specific people
Make sure it is directly related to your goals
Use helpful opening phrases (“I think I missed the patient’s reaction. What do you think?”)
Ask for recommendations
Never compare the feedback from others openly
Thank them for their information
Decide what to do with the input
Consider it one data point or one puzzle piece
If you do use their feedback, let them know about it in the future

Sender
• Create a supportive atmosphere
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Realize the person is asking for guidance, not criticism
Clarify what the person wants feedback on (“What do you specifically want to know?”)
• Listen to their self-assessment and respond accordingly
• When finished, ask if that is what they wanted to know
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Respond with respect
Help the person create an action plan —don’t tell them what to do
• Follow up in the future

• Giving Feedback
• Teach first
• Very focused
• Receiving Feedback
• Active listening
• Remember it is just another data point
• Soliciting Feedback
• Ask specifically
• Follow up

• Key Observations:
• The student is strong academically
• Learns little about patients psychosocial situation
• Disrespectful to patients and unprofessional when discussing patients with others
• Disrespectful to the nursing staff
• A resident complained the students jokes were in bad taste
• What would you say?

• Acknowledge excellent academic performance
• Have first hand knowledge of concerns
• Explore reason for behavior: Anxious? Trying to fit in?
Truly malicious?
• Confront the student directly with unprofessional behavior
• Establish rules of professional conduct
• Emphasize that interpersonal skills can be learned and improved
• Provide reading materials on effective doctor-patient communication
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Mentally rehearse discussion
Use the “feedback sandwich”
• Start and end with positive comments
• Take a break if you start to feel flustered

Compliment
Criticism
Compliment

• Key Observations:
• The students presentations are well organized and thorough
• The student is reliable and willing to do whatever is asked
• The student is difficult to get to know and does not participate unless directly questioned
• The student does not seek out the team and offer to help but is willing when asked
• The student seems uncomfortable participating in discussion around others students’ patients
• What would you say?

• Acknowledge the student’s strengths
• Note lack of participation in groups; has this been an issue in the past?
• Emphasize value placed on being a visible, active member of the team
• Stress that group participation is a skill; discomfort can be overcome
• Provide suggestions for ways student might increase assertiveness and participation:
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• Set goal of asking at least one question per day on rounds
Ask student to role play with you an interaction with a busy resident
Ask student to call and speak with a consultant in your presence
Enlist help of a resident with these goals

• Key Observations:
• The student is very confident in his clinical abilities
• However, the students fund of knowledge is spotty and he/she demonstrates trouble synthesizing data
• The student has been argumentative on rounds and undercuts other students and housestaff
• The students write up and presentations are disorganized
• What would you say?

• Acknowledge achievements but note the relative lack of clinical experience
• Point out observations about specific areas of improvement with specific examples of performance deficits. Reframe if needed.
• Be assertive in your critique
• Stand behind your judgment
• Focus on the problem not the person
• Point out that teamwork is essential to the achievement of student’s goals

• True or False: Feedback should be formative in nature
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• True
False
• True or False: Feedback is an effective teaching strategy
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• True
False
• True or False: Feedback takes a minimum of 10 minutes to be an effective teaching tool
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• True
False
• True or False: Studies demonstrate that most trainees feel they receive adequate feedback on their performance during training
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• True
False

• True or False: Studies demonstrate that provision of specific constructive feedback can improve procedural skills
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• True
False
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• True or False: Setting expectations upfront facilitates effective feedback
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• True
False
True or False: Feedback should be timely and specific
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• True
False
• True or False: Constructive feedback should be limited to 2-4 specific items
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• True
False

• Be fair
• Be specific
• Be consistent
• Be ongoing
• Be timely
• Be open
• Be collaborative
• Be explicit
• Be routine

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