Strategies for
Effective Feedback
in Medical Education
PROFESSIONAL DEVELOPMENT
Basics Program for New Faculty – Day 1: October 3, 2013
Presenters: Sarah Fleming MD CCFP, Gweneth Sampson MD CCFP FCFP MScCH
Facilitators:
Helen Batty, Allyson Merbaum, Sarah Reid, Michael Roberts, Gweneth Sampson,
Find this slide presentation at www.dfcmopen.com/item/effectivefeedback-in-meded
Monica Sethi, Barbara Stubbs
This set of slides is adapted for DFCM
Open. You can download these slides at
www.dfcmopen.com/item/effective‐feedba
ck-in-meded.
Find a handy one-page reference about
giving feedback at
www.dfcmopen.com/item/giving-feedbackbasics.
Find this slide presentation at www.dfcmopen.com/item/effectivefeedback-in-meded
The objectives of the “one-pager”, which includes
a list of references, are as follows:
1. Describe the role, models and characteristics of
constructive feedback in education.
2. Understand some of the common challenges
and barriers to effective feedback, including the
role of student self-assessment.
Find this slide presentation at www.dfcmopen.com/item/effectivefeedback-in-meded
LEARNING OBJECTIVES
• Participants will be able to:
– Describe the role, models, and
characteristics of constructive
feedback in education
– Understand some of the common
challenges and barriers to effective
feedback, including the role of student
self assessment
– Demonstrate feedback techniques
OVERVIEW OF WORKSHOP
• Background Information
• DVD: Resident scenario
• Feedback Role Play
• Feedback Checklist
• DVD: Small Group Exercise
• Summary
KEY MESSAGES
• Trainees state that feedback is the main item they don’t
get enough of in teaching sessions (Hewson and
Little,1998)
• The process of giving feedback is as important and
structured as taking a good history
• Focusing on attaining a comprehensive student selfassessment and establishing a dialogue are keys to
good feedback (Ende, 1983; Ramani & Krackov, 2012)
• We need to give better feedback - not necessarily more
FEEDBACK: DEFINITIONS
• Feedback is the sharing of information on
actual performance to help guide the
student’s future performance toward a
desired goal (Ramaprasad, 1983)
• It is essential to learning
• It requires a sample behaviour, a clear
model of the desired behaviour, and a
demonstration of the difference between the
two
TYPES OF FEEDBACK
Formative
• Aimed at
improvement
• Gathered to
inform change
Summative
• After-the fact
• Evaluation
• Judgment
• Eg. Field Notes
• Eg. End of Rotation
Evaluations (ITERS)
Feedback is most useful when provided
during a formative evaluation
(Sadler,1989)
WHY GIVE FEEDBACK?
“Feedback can change physicians’
clinical performance when provided
systematically over time by an
authoritative credible source”
(Velosky et al., 2006)
FEEDBACK MODELS
•
Sandwich Technique
“positive/negative/positive”
•
Pendleton Method (Cantillon and Sargeant, 2008)
•
Relative Ranking System
•
EFPO “6 Step” Model (Educating Future Physicians
of Ontario)
EFPO MODEL OF FEEDBACK
(SIX STEP)
1. Teacher observation of student behaviour or work
2. Ask the student for their self-assessment
3. Describe the desired behaviour
4. Ascertain that the student understands the
difference between current behaviour and desired
behaviour
5. Elaborate a plan to close the gap (an educational
prescription)
6. Follow-up on improvement
Merrilee Brown, Brian Hodges, J.Wakefield, Effective Feedback, 1995
AN EXAMPLE - PARALLEL
PARKING
1. Observe student parallel parking (too far from the curb)
2. Ask for self assessment - “How do you think that
went?” “What did you do well?”… “Is there anything that
didn’t go as well as you had hoped?”
3. Describe desired behaviour - “You did a great job at
checking the space around the car. Next time I would
recommend parking closer to the curb… Indeed, this can
be tricky sometimes”
4. Check if student understands the difference between
current parking and desired parking – “What do you think
about my suggestion of parking closer to the curb?” “How
much closer would you like to be next time?”…“Yes, two
feet closer sounds good”
AN EXAMPLE - PARALLEL
PARKING
5. Make a Plan to close the gap - “Is there anything that you
can think of that may improve it for next time?” … “ I agree,
and you could also try slowing down the car as you reverse.
Why don’t you watch me park, then practice this again for 10
minutes every day”
6. Follow-up on improvement - “I will observe you park again in
3 days and we can touch base to see how things are going”
CHARACTERISTICS OF EFFECTIVE
FEEDBACK
CHARACTERISTICS OF
EFFECTIVE FEEDBACK: CORBS
Characteristics of Effective Feedback:
•
•
•
•
•
Clear
Observed (and Owned)
Regular / Restricted
Balanced
Specific
POSSIBLE BARRIERS TO THE
PROVISION OF EFFECTIVE FEEDBACK
• Little or no instruction on how to give feedback
• Fear of damaging relationship with learners
• Hierarchy issues between teacher and learner
• Cultural context issues
• Students’ ability to self-assess
SELF-ASSESSMENT OF
COMPETENCE: WHY IS IT AN IMPORTANT SKILL?
• Leads to increased motivation and
improved knowledge, communication and
performance (Evans, 2002)
• The ability to accurately assess one’s
own strengths and weaknesses is the first
step in self-directed learning (Boud, 1990)
• Physicians are responsible for their own
continuing medical education
SELF-ASSESSMENT OF
COMPETENCE:
Are we good at self-assessment?
SELF-ASSESSMENT OF
COMPETENCE:
Self assessment
high
Risk group
(Dunning and Kruger, 1999)
Risk group
Burnout
potential
Vicious cycle of
incompetence
Competence
low
average
high
SELF-ASSESSMENT OF
COMPETENCE:
Can we improve our self-assessment skills?
SELF-ASSESSMENT OF
COMPETENCE:
(Dunning and Kruger, 1999)
Self assessment
high
Risk group
Improved
competence
creates
improved self
assessment
skills
Risk group
Burnout
potential
Competence
low
- insight
- ability to use
feedback
average
high
SELF-ASSESSMENT OF
COMPETENCE:
Self assessment
high
(Dunning and Kruger, 1999)
Improvement in self
assessment after
viewing “benchmark”
videos
(Martin et al., 2004)
low
average
high
Competence
FEEDBACK AND REFLECTION
• Feedback  self-assessment  reflection
• Although self-assessment is often inaccurate, self
assessment skills can be learned
• Reflection and self-assessment are critical for lifelong
learning
• Reflection accelerates learning and improves the
depth of understanding (Westberg & Jason, 2001)
• Reflective practioners are likely to provide better
patient care
USEFUL RULES FOR ROLE-PLAY
AND DEBRIEFING
• Preferable to recruit volunteers, not assign roles
• Refusal always allowed
• Time out whenever needed “T”
• Role players debrief first
– most anxiety provoking roles first (no interrupting)
– may be given a reasonable time limit in advance
• Role players discuss first
– with each other
– ask observers questions for specific feedback and advise them of
areas “off limits” for comment
• Observers provide specific careful feedback following guidelines
– use data from field notes “quotations” etc.
– respect requests and limitations set by role players
• Time keeper keeps track of start and stop times
Batty’s Rule: 1 minute of role playing  2 to 10 minutes of debriefing
LARGE GROUP DEBRIEF
• What strategies worked?
• What was a challenge?
• What will you try in future?
WRAP-UP - REVIEW OF OUR
LEARNING OBJECTIVES
• Participants will be able to:
– Describe the role, models, and
characteristics of constructive
feedback
– Understand some of the common
challenges
– Demonstrate feedback techniques
PRACTICAL TIPS
•
•
•
•
•
•
Label this as “Feedback”
Think about Timing and Privacy
Link to Learner’s Objectives
Provide Opportunity for Change
Get Feedback on your Feedback
Follow-Up
KEY MESSAGES
• Feedback is crucial to the improvement of
performance, self assessment skills and reflective
practice
• Process = 6 step EFPO model: observe, student selfassessment, describe behaviour, describe the gap,
make an educational plan and follow up
• CORBS: Clear, Observed, Regular, Balanced,
Specific
• Just do it (and label it!)
REFERENCES
•
•
•
•
•
•
•
Branch W and Paranjape A (2002). Feedback and Reflection: Teaching Methods
for Clinical Settings. Academic Medicine 77 (12): 1185-1188
Cantillon P and Sargeant J (2008). Giving feedback in clinical settings. BMJ
337:a1961.
Davis D, Mazmanian P, Fordis M, Van Harrison R, Thorpe K, Perrier L (2006).
Accuracy of Physician self-assessment compared with observed measure.
JAMA 296(9):1094-110
Dunning D, Kruger, J (1999). Unskilled and Unaware of It: How Difficulties in
Recognizing One's Own Incompetence Lead to Inflated Self-Assessments.
Journal of Personality and Social Psychology 77 (6): 1121-34.
Eva K and Regehr G (2013). Effective feedback for maintenance of
competence: from data delivery to trusting dialogues. CMAJ April 2; 185:463464
Evans A, McKenna C, Oliver M. (2002). Self-assessment in medical practice. J
R Soc Med 95:511-513.
Hewson MG, Little ML. (1998). Giving feedback in medical education:
Verification of recommended techniques. J Gen Intern Med 113:111–118.
REFERENCES
•Mann K, Gordon J, Macleod A. (2007) Reflection and reflective practice in health
professions education: a systematic review. Adv Health Sci Edic Theory
Pract 2007;14:595-621.
•Martin D, Regehr G, Hodges B, McNaughton N. (1998) Using videotaped
benchmarks to improve the self-assessment ability of family practice residents. Acad
Med. Nov 73(11): 1201-6.
•Ramani S, Krackov S. (2012). Twelve tips for giving feedback effectively in the
clinical environment. Medical Teacher 34:787-791.
•Ramaprasad A (1983) On the definition of feedback. Behav Sci 28:4-13.
•Sadler, DR (1989) Formative assessment and the design of instructional systems.
Instructional Science 18:119-144.
•Sandars J. (2009). The use of reflection in medical education: AMEE guide 44. Med
Teach 31:685-95.
•Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. (2006). Systematic
review of the literature on assessment, feedback and physicians' clinical
performance: BEME Guide No. 7. Med Teach. Mar;28(2):117-28.
•Westberg, Jane & Jason, Hilliard. (2001) Fostering Reflection and Providing
Feedback, New York: Springer Publishing Co.
Thank You!
Find this slide presentation at www.dfcmopen.com/item/effectivefeedback-in-meded