AskTellAsk: A Tastier Feedback Sandwich

1
Ask-Tell-Ask A Tastier Feedback Sandwich

• Lyuba Konopasek, MD
• Associate Professor of Pediatrics,
• Director, Faculty Development NYPH GME

2
Plans for the day

• Describe rationale for giving feedback
• Distinguish feedback from minimal feedback and
  evaluation of learners
• Describe essential elements of giving effective
  feedback
• Demonstrate the Ask-Tell-Ask feedback technique
• Analyze and practice giving feedback

3
Rationale for Giving Feedback in Medical Education

• Without feedback, mistakes go uncorrected,
  good performance is not reinforced, and clinical
  competence is achieved empirically or, not at
  all.

Ende J. Feedback in Clinical Medical Education.
JAMA 1983250777-781.
4
The Game

• I am thinking of a number between 1 and 100.

5
How do they differ?

• Minimal feedback
• Evaluation
• Feedback

6
Minimal Feedback(Compliment/Criticism)

• Statement expressing positive (or negative)
  reaction to a behavior which aims to increase (or
  decrease) the likelihood of that behavior
  happening again
• That was a great presentation
• You need to work on your presentation skills
• Often mistaken for feedback
• Timing is similar - immediate

7
Evaluation

• Qualitative or quantitative judgment which ranks
  a learners performance in comparison to other
  learners
• Honors on the Peds clerkship
• 3.7 for Professionalism
• Often the only measure of performance visible to
  the learner
• Usually given after the performance is over

8
Feedback

• (Reinforcement or correction) Explanation
• Keeps you on course to meet your goals
• Allows you to adjust your course to meet goals
• Given immediately after the performance or some
  time soon after, when the learner still has some
  time to demonstrate improvement

9
What are essential components of feedback?

• What was done well
• What could be done better
• What could be done to improve next time

10
Characteristics of Effective Feedback

• Well timed and expected
• Based on first hand data
• Regulated in quantity
• Phrased in descriptive language, based on
  specific remediable behaviors
• Should be undertaken with teacher and learner
  working as allies, with common goals

Ende J. Feedback in Clinical Medical Education.
JAMA 1983 250 777-781
11
Types of Feedback in Medical Education

• Brief feedback - 2-5 minutes
• Routine
• In the context of every day work
• On a clinical skill
• Major feedback - 10-30 minutes
• Scheduled at end and/or mid-point through a
  learning experience
• Remedial feedback

Branch J, Paranjape A. Feedback and Reflection
Teaching Methods for Clinical Settings. Academic
Medicine. 2002771185-1188.
12
The Old Feedback Sandwich
Praise Criticism Praise Is it more
palatable?
13
The New Feedback Sandwich
Ask Tell Ask
14
Ask

• Ask learner to assess own performance first
• Phrase question to encourage meaningful
  reflection
• What went well and what could have gone better?
• What were your goals?
• Have they ever seen a patient like this before?
• Make sure to allow adequate time for the answer
• Begins a conversation
• Assesses learners level of insight
• Helps you diagnose the learner
• Promotes self-assessment and reflective practice

15
Tell

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

16
Limit the Quantity
17
Ask (again)

• Ask about recipients understanding and strategies
  for improvement
• What could you do differently?
• Again, give ample time
• Give own suggestions
• Perhaps even replay parts of the encounter show
  me
• Close by committing to monitor improvement
  together

18
Feedback Planning

• Why is it important to do?
• Agent
• Who is going to do it?
• Timing
• When will it happen?
• Venue
• Where will it happen?
• Content/behavioral attributes
• Do you know the specifics?

19
BEFORE Prepare Effectively

• Plan what you will say
• Play out the conversation in your head
• Your opening question
• Make sure that you have enough information
• Is it specific and behaviorally based?
• Think about who else you need to collect
  information from
• If feedback is second hand, do you have enough
  specific, behaviorally based information?
• Was it documented by the other person?
• Consider your relationship
• What is it? How well do you know this person?
• How long will you have it?

20
AFTER Giving Feedback Reflect 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?
• Do you need to tell anyone else?
• Consider your relationship
• How has this session affected it?

21
See one
22
Do one

• Role play in pairs
• Feedback giver
• Feedback receiver
• Debrief
• Feedback receiver gives feedback on the feedback

23
The Feedback Dialogue

• Ask learner to assess own performance first
• What went well and what could have gone better?
• Tell what you observed diagnosis and explanation
• React to the learners observation
• Include both positive and constructive elements
• Give reasons in the context of well-defined
  shared goals
• Regulate quantity
• Ask about recipients understanding and strategies
  for improvement
• What could you do differently?
• Give own suggestions
• Perhaps even replay parts of the encounter - show
  me
• Commit to monitoring improvement together

24
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.