Giving Effective Feedback

Using the RIME Method for
Effective, Brief Evaluation &
Feedback in the Clinical Setting
Explain the purpose of the RIME feedback
2. Describe the RIME Schema and associated
3. Practice using this method to give feedback.
4. Reflect on the outcomes of using this method and
consider ways to improve your application of the
method in the future.
What is it?
The R-I-M-E Method
 Provides a systematic, objective framework to “diagnose” a learner’s
functional level & then provide recommendations on how to move to
the next level;
 Uses manageable, observable & easily understood concepts that
demonstrate growing levels of professional knowledge & behavior;
 Facilitates focused verbal assessment of learners on competencies
such as problem identification, reasoning, communication, physical
examination, written documentation, & professional attributes;
 Allows clear, brief, meaningful & useful feedback to learners in a
timely manner.
How Does it Work?
The RIME method, developed by Louis Pangaro, MD
allows brief, constructive & timely evaluation & feedback,
uses a simple level of competency rubric,
reinforces appropriate behavior,
motivates students via immediate, brief, focused & constructive feedback,
can improve inter-rater reliability by providing a systematic rubric.
The RIME schema describes expected cognitive & behavioral progression in the development of
medical skills. Instructors use the competency schema to:
quickly assess student performance,
decide what skills to provide feedback on at each teaching opportunity,
frame their feedback so as to encourage significant improvement.
Pangaro, LN. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999
The learner:
 accurately gathers & clearly communicates the
clinical facts on his/her patients,
 demonstrates a clear sense of responsibility,
 develops consistency in “bedside” skills.
These skills must be mastered as a criterion for passing
the clerkship (and to fulfill competencies required
for graduation).
 Transitioning from “reporter” to “interpreter” is
essential for a third year student, but often very
 Clinical test data provide an “interpreting” opportunity
that requires:
a high level of knowledge,
 skill in selecting clinical findings that support the diagnosis,
 skill in applying results appropriately in a specific case.
 The student must transition emotionally & cognitively
from “bystander” to active participant in patient care.
 Requires increasing knowledge, confidence &
judgment in deciding when action needs to be taken
and in selecting among & proposing options for
patient care.
 Student must learn to tailor the plan to the patient’s
specific circumstances & preferences.
 Can’t expect that a student’s diagnostic & treatment
suggestions will always be “right”– so it’s best to ask
them for 3 options.
 Success in each prior step depends on self-directed
learning & mastery of basics.
 An advanced trainee (educator level) will demonstrate:
the drive to look for evidence on which clinical practice can be
 the skill to recognize evidence that can stand up to scrutiny,
 going beyond the required basics to read deeply and share new
learning with others,
 the insight to identify questions that are important to research in
more detail,
 the maturity & confidence to share leadership in educating the team
(and even the faculty).
Behaviors for Feedback
RIME Schema
Reliably, respectfully, honestly gathers information from
patients & communicates clearly with faculty.
 Gets the basic work done.
 Answers the “what” questions.
Presentation shows selectivity, prioritization & implies
 Demonstrates active involvement in thinking through the
patient’s problems, interpreting the data & acquiring the
knowledge to offer a reasonable differential diagnosis.
 Answers the “why” questions.
Works with patients on diagnostic & therapeutic decisions,
continually developing expertise -- as demonstrated in
clinical planning.
 Consistently answers “how” to resolve problems.
Personal planning & reflection demonstrate a commitment
to develop expertise.
 Demonstrates ongoing efforts to self-correct & improve.
Tips for Using the RIME Method
 Evaluate or “diagnose” the
learner based on current level of
knowledge & skill development,
as well as any noticeable
improvements in performance.
 Recognize that the learner’s
development is in process, and
consider performance in that
 Carry a pocket-sized card that
summarizes the RIME levels so
you can refer to it quickly when
giving feedback, and can share
the rubric with the learner.
 Avoid personal biases &
comparisons with others when
assessing the learner’s
 It is most effective to focus first
on what the learner has achieved,
and then briefly highlight areas
where you see the possibility for
further growth.
 Maximize the learner’s
motivation to improve by using
constructive, encouraging words
& giving clear examples of how to
change his/her behavior.
Quick Review
The RIME feedback method is designed to provide:
a. a detailed & comprehensive method for competency-based
feedback & evaluation.
b. a quick & easy method for meaningful, competency-based
feedback & evaluation.
c. a system of feedback & evaluation that allows learners to guide the
feedback process in order to improve their clinical skills.
One example of a competency that can be evaluated effectively using
the RIME method is:
a. showing commitment to self-correction & self-improvement.
b. accepting that, as learners, the resolution of problems will be above
their skill level.
c. always relying on the attending or resident to outline a treatment
Quick Review
3. To give effective feedback to a student via the RIME method, you:
a. Ask her to write a comprehensive H&P, then present the patient to
you with differential & detailed recommendations for a treatment
plan. After finishing your rounds for the day, you review the student’s
written recommendations and then give her feedback the next time
she rounds with you.
b. Check to see if she has transitioned from an observer to an active
participant in the patient’s care by asking her for a diagnosis &
treatment plan (“Manager” level). You then reinforce any accuracies
in her diagnosis & treatment plan, and ask her opinion about
alternatives you think she should consider.
c. Point out the fact that her diagnosis & treatment suggestions are
inaccurate and unfounded based on details of the patient’s history that
the student seems to have ignored. You suggest that, if she wishes to
become a competent physician, she should be more thorough and pay
better attention to details.
Quick Review
4. To improve your application of the RIME method
in the future, it would be helpful to:
a. Reflect on the fact that the student is still developing
clinical skills, so you should focus on pointing out errors
and shortcomings to help improve performance in the
b. Realize that the student will likely be able to perform
better next time if you point out how well student “x”
performs, and set that as a goal for the student to work
c. Reflect on the student’s response to your feedback, and
adjust your style of communication in the future to
provide encouragement for her to continue learning &
 1. (b) much of the value of the method is due to it’s ease of use
& brevity. Therefore, “a” is wrong because it suggests
a long, complex process; and “c” is wrong because the
instructor, not the student, should guide the process.
 2. (a) is correct because it reflects a developing competency,
while “b” and “c” do not indicate any motivation to
develop skills of analysis & planning.
 3. (b) reflects appropriate use of the RIME model & skill
in encouraging the learner; “a” involves too much time
lapse, and “c” discourages the learner.
 4. (c) will help you reframe your teaching to encourage
the student to do better; while “a” & “b” will
reinforce your thinking that the student is a poor
performer and will likely lead to behaviors that will
discourage her improvement.
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