Beyond the Feedback Sandwich:

1
Beyond the Feedback Sandwich Fun Tools for
Improving Feedback Skills
2
Objectives

• Describe rationale for giving feedback
• Discuss barriers to giving effective feedback
• Practice analyzing teaching videos
• Describe process of giving effective feedback for
  lifelong learning including the incorporation
  of reflection into the process

3
Rationale for Giving Feedback

• Without feedback, mistakes go uncorrected, good
  performance is not reinforced, and clinical
  competence is achieved empirically or, not at
  all.
• Good feedback promotes the skill of reflection,
  which is essential for the development of
  expertise and lifelong learning.
• Its required by the LCME and ACGME.

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781. Bing-You RG, Trowbridge
RL. Why medical educators may be failing at
feedback. JAMA 20093021330-1331.
4
Feedback

• (Reinforcement or correction) Explanation
• Keeps learner on course to meet goals
• No judgment against external standards no matter
  where learner is in relation to external
  standards, feedback is always helpful
• Best if given immediately after the performance
  or at some time soon after, when the learner
  still has time to demonstrate improvement
• If done well, the learner does not feel judged,
  enhances capacity for reflection, and therefore
  lifelong professional development

5
Ende Principles of Good Feedback

• Aligns the goals of teacher and learner
• Is well-timed and expected
• Is based on first hand observation
• Is regulated in quantity and limited to
  remediable behavior
• Is phrased in descriptive, non-evaluative
  language
• Deals with specific performance
• Deals with decisions and actions rather than
  assumed intentions or interpretations

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781.
6
What are the biggest challenges to giving good
feedback?
7
Why are educators failing at feedback?

• 1) Not learner-centered/without awareness of the
  learners perspective or self-assessment
• 2) Overpowering of affective reactions to
  feedback / a failure to separate the behavior and
  the person (for teacher and/or learner)
• 3) Unsuccessful feedback teaches learner to fear
  or avoid feedback in the future

Bing-You RG, Trowbridge RL. Why medical educators
may be failing at feedback. JAMA
20093021330-1331.
8
Domains of feedback

• Knowledge
• Skills
• Attitude
• ?Professionalism

9
Sleeping Video Part 1

• Take notes on what you observe
• What did the residents think of the student?
• What feedback was delivered?
• How did the student respond?
• Discuss with your partner

10
VIDEO
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Sleeping Video Part 2

• Here are the same residents after additional
  training
• What was done differently?
• Do you detect a different structure to the
  feedback?
• How did the student respond?
• Discuss with your partner

12
VIDEO
13
What more could the resident have done?

• Make explicit what was learned
• This is an important opportunity to learn how
  to balance your personal and professional lives.
  When something in your personal life starts to
  impact your professional performance, you need to
  tell colleagues and ask for help in handling the
  situation and/or ensuring your professional
  obligations to others are fulfilled.

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Professionalism

• Expected
• Responsible and reliable
• Industrious and dedicated
• Enthusiastic and motivated
• Appropriately respectful and empathic
• Honest and trustworthy

• More advanced
• Self directed takes responsibility for learning
  and behavior
• Actions based on accurate understanding of
  perspectives and needs of others including
  patients, team
• Overcomes performance preoccupation to focus on
  patients and learning

15
The Old Feedback Sandwich
Praise Criticism Praise
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The New Feedback Sandwich
Ask Tell Ask
Lyuba Konopasek, MD in prep for publication
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Ask

• Ask learner to assess own performance first
• Begins a conversation an interactive process
• Assesses learners level of insight and stage of
  learning
• Less threatening separating behavior from self
• Promotes reflective practice

18
Tell

• Tell what you observed diagnosis and explanation
• React to the learners observation
• Feedback on self-assessment
• Include both positive and corrective elements
• I observed.
• Give reasons in the context of well-defined
  shared goals

19
Ask (again)

• Ask about recipients understanding and strategies
  for improvement
• What could you do differently?
• Give own suggestions
• Commit to monitoring improvement together

20
Limit the Quantity
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BEFORE Giving Feedback Prepare Effectively

• Set a time major feedback should not take
  student by surprise
• Plan what you will say
• Make sure that you have enough information
• If feedback is second hand, try to obtain
  specific, documented behaviorally based
  information

22
AFTER Giving FeedbackReflect on How it Went

• What was effective?
• What could be done differently?
• Were you well prepared?
• Future strategies
• Do you need to document?
• Do you need help?

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Benefits of Ask-Tell-Ask

• Learner centered incorporating the learners
  perspective
• Active and interactive
• Avoids assumptions or judgment
• Reflection may make it easier to separate the
  behavior from the person
• Promotes lifelong skill of reflection
• These are basic communication skills and allows
  us to put the diagnosis before the treatment

Branch J, Paranjape A. Feedback and Reflection
Teaching Methods for Clinical Settings. Academic
Medicine. 2002771185-1188.
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End with Ende

• The important things to remember about
  feedback in medical education are that (1) it is
  necessary, (2) it is valuable, and (3) after a
  bit of practice and planning, it is not as
  difficult as one might think.
• --Jack Ende, MD

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781.
25
Acknowledgements

• Funding
• Glenda Garvey Teaching Academy, Columbia
  University
• Actors
• Maya Castillo
• Thomas Hooven
• Benjamin Kennedy
• Daniel Vo

• Lyuba Konopasek, MD
• Andrew Mutnick, MD
• John Encandela, PhD
• Gingi Pica, MPH
• Center for New Media and Technology
• Michelle Hall, BS