MEDICAL EDUCATION

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Notes for the Primary Care Teachers
GIVING FEEDBACK

Good feedback should observe the following guidelines:

1. Comments on observable behaviour and not on assumed intentions or interpretations.
• Instead of saying “You were nervous about explaining the consent form to the family”
• “I thought you look uneasy when you were explaining the procedure; how did you feel?”
2. Provide positive comments first to give the learner confidence.
3. Emphasise the sharing of information between the teacher and learner.
• Ask learner what he / she thought of his / her performance, encourage him / her to be his / her own critics and offer observations when needed. This will transform feedback situation to a discussion of actions and problems.
4. Feedback should be given at an appropriate place and time and in private. It is a personal learning matter, the learner must not be made to feel uncomfortable or embarrassed.
5. Discussion of specific behaviours helps to avoid meaningless commentary. Both learner and teacher are more comfortable with factual approach. Instead of saying, “Good job”; be more specific, “Your case presentation was clear and well organised”.
6. Focus on behaviours that the learner can control and modify; it should deal with decisions and actions. It is frustrating or demeaning to the learner to expect a change that is beyond their control.
7. Learners should be asked to verify feedbacks. By asking the learner to agree or disagree and restate the feedback the teacher can be assured that the learner has understood the nature and content of the feedback.
8. Feedback requires preparation and ability to tolerate discomfort and criticism. The teacher must establish a bond of constructive understanding that enables the learner to appreciate that feedback is not personal judgment but aimed at improved performance.

COMMUNICATION SKILLS FOR PROVIDING EFFECTIVE FEEDBACK5

Focused on specifics

Avoid:       “You seem disorganized.”
Instead:    “When you present a case, go through your findings on the history taking and physical examination before suggesting a treatment plan.”

Non judgmental

Avoid:       “Sometimes you are too abrupt with patients.”
Instead:    “There are some things that can make the patient feel more comfortable. When she walks into the consultation room, greet her, introduce yourself, ask open ended questions first to allow the patient to tell you her problems in her own way.”

Objective

Do not infer things about the learner that may not be true.
Avoid:       “You seem disinterested when patient talks to you.”
Instead:     “I notice sometime that you look at your watch when patient talks to you. Were you in a hurry?”

Limited

Choose one or two important items to focus on rather than several items.

Expected

When rotation begins announce that you will give periodic feedback.
Preface specific observations with “I would like to give you some feedback.”

Timely

Immediate feedback is important for formative learning as it will still be in the learner’s immediate memory.

Ask, Tell, Ask Model

• ASK the learner how he thought he did
  “How did you think the history taking part of the interaction appear to be?”
  
• TELL the learner what you observed
  “The questions you asked were very thorough. You gathered all the necessary information. One thing I noticed was that when the patient expressed his frustrations you did not acknowledge that frustrations. I found relationship with a patient is strengthened when I simply acknowledge the difficulties he is having. Saying something like, “I can tell this is frustrating for you. I think we are able to provide you some ways to make life a bit easier”
• ASK the learner how you can help her improve
  “What could I do to help you feel more comfortable in a situation like that in future?”

CONCLUSION
Giving feedback whether reinforcing or corrective is an essential component of clinical education. We are training physicians to develop a lifelong process of monitoring skills and decisions and an effective feedback system is the mainstay of such an action.4

REFERENCES

1. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-81 [PubMed] [Link]
2. Vickery AW, Lake FR. Teaching on the run tips 10: giving feedback. Med J Aust. 2005;183(5):267-8 [PubMed] [Full text]
3. Wood BP. Feedback:  A key feature of medical training. Radiology. 2000;215(1):17-19 [PubMed] [Full text]
4. Boehler ML, Rogers DA, Schwind CJ, et al. An investigation of medical student reactions to feedback: a randomised controlled trial. Med Educ. 2006;40:746-9 [PubMed]
5. Bylund C. Director, ACGME Outcome Project, New York – Presbyterian 305-2296 [Link]