Giving Effective Feedback

to Residents in the
Emergency Department
Patrick Brunett, MD, FACEP
Oregon Health & Science University
Portland, Oregon USA

Acknowledgements
The presenter wishes to acknowledge the contributions of the
following individuals in the preparation of these slides:

Judith Bowen, MD
Esther Choo, MD
Todd Ellingson, MD
Sarah Gaines, MD
Susan Promes, MD
Lalena Yarris, MD

Overview
Introduction
Why give feedback?
Obstacles to effective feedback
Techniques
Examples
Promoting feedback
One Minute Preceptor

Feedback vs. Evaluation

Feedback

Timely
Based on specific observed behaviors
Neutral, information
Level-based
Directed toward the learner
Formative (goal to improve future performance)

Feedback vs. Evaluation

Evaluation

Appraisal of performance over time

Directed toward learner and program leadership
Scheduled intervals
Level-based and competency-based
Information and judgment
Assesses readiness for advancement

Core Competencies
Medical knowledge
Patient care
Practice-based learning
Interpersonal and communication skills
Professionalism
Systems-based practice

Why give feedback?

Essential to clinical education
Learners want feedback
Required by regulatory bodies (ACGME)
Without feedback

Learning is inefficient

See only minimal improvements, even in highly
motivated learners

Barriers to Effective Feedback

I dont have time

Effective feedback takes little time

30 to 90 seconds
Quality, not quantity, feedback valued by learners
Instructors believe effective feedback requires
more time than learners (Yarris, et al 2008)

Barriers to Effective Feedback

Feedback is not recognized by learners

Instructors perception of quantity and frequency
of feedback provided far greater than learners
perception of feedback received

Uncomfortable giving negative feedback

No long term contact; self doubt
Requires proper setting, tone, structure

Barriers to Effective Feedback

Feedback is given but ineffective:

Great job!
Excellent
Had a good shift
Need some improvement
Hard worker
Work harder

Barriers to Effective Feedback

Instructor
observe
interpret
formulate
deliver

Learner
expect
receive
decode
respond

Techniques
Take a pause from activity
Be friendly, supportive, approachable
Make eye contact
Draw out the learner

How do you think that encounter went?

Did you feel comfortable performing that
procedure?

What is your understanding of this clinical
problem?

Techniques
Begin by complimenting good behavior

I really liked the way you

You seem to be very comfortable with

You did a very nice job with

Techniques
Focus on one or two key points for
constructive feedback
Be VERY specific
Explore breadth and depth of learners
knowledge base
Provide information, not criticism
Objectively examine performance with
the learner

Techniques
Sandwich Technique
Positive
Constructive
Task/Plan

Positive

Constructive

Chocolate Sundae Technique

Positive

Techniques
Make a plan for improvement

Selected readings, articles, websites

Reexamination of patient, images, lab

Specific follow up

Come back and well discuss the patient again

Once youve done X, tell me what you found

Techniques

Give feedback immediately

Give feedback often
Be brief (30 to 90 seconds)
Be concise
Do not give a mini lecture

Methods of Feedback
Face to face

Most powerful

Most difficult

Email comments
Electronic residency management system

E*Value, New Innovations

Shift Cards

Methods of Feedback

Methods of Feedback

Methods of Feedback

Methods of Feedback

Promoting Feedback
Faculty Development courses
Support from department leadership
Teach residents to ask for and expect
feedback
On line resources:
http://www.emresidency.ucsf.edu/Resource/Feedback
MovieFinal.html

One Minute Preceptor Model

Initially described by Neher et al 1992
Fosters learner ownership
Identifies knowledge gaps
Focuses learning issues

One Minute Preceptor Model

Teaching the One Minute Preceptor
(Furney et al)

Randomized controlled trial

28 residents received a 1-hour session vs. 29 residents
in control group
Taught students using OMP model
Easy to learn and implement
Satisfaction for both the teachers and the learners

One Minute Preceptor Model

Five Microskills

#1 Get a commitment
#2 Probe for supporting evidence
#3 Teach general rules
#4 Reinforce what was right
#5 Correct mistakes

Get a Commitment
Gives learner sense of responsibility for
patient care
Determine how the learner views the
case

Get a Commitment

What do you think is going on?

Why do you think the patient has not been
taking their medications?

What is the next step you would like to do in the
work-up?

Get a Commitment
Ineffective technique:

I think this sounds like a MI, dont you agree?

Anything else?

I think you are way off

Probe for Supporting Evidence

The preceptor is diagnosing the learner
Probing their

Knowledge base
Understanding of situation
Ability to reason
Attitudes and biases

Probe for Supporting Evidence

What has made you think that this is
pneumonia?

What else did you consider?

Why do you think this is not a dissection?

What are the major findings in this case
that led you to that conclusion?

Probe for Supporting Evidence

Bad Examples:

Dont you have any other ideas?

This is obviously a classic case of..

Guess what I am thinking

Teach General Rules

Focus on specific competencies
relevant to this particular learner

Check for learner understanding of
what you are discussing

Helps to generalize to future cases

Teach General Rules

If the patient has pneumonia and is
hypoxic, oxygen should be started
immediately.

Antibiotics should be started in the ED
but will not help fix their initial
hypoxia.

Teach General Rules

Bad Examples:

This patient is in heart failure and needs a diuretic

Dont start the beta blocker now

I always give antibiotics to this type of patient

Reinforce What Was Done Right

Be specific with what was done well
Explain why their performance was good
Give specific praise

Reinforce What They Did Right

Examples

You considered the patients allergy history when
you chose that antibiotic. That was excellent and
helps ensure the patients safety.

You were very sensitive to the emotional needs
of the family. You earned their trust.

Reinforcebad example
More Bad Examples:

Great job! (with what?)

That was the right treatment (explain why)

Correct Mistakes

Teach the learner how to avoid
repeating the same error in the future.

Uncorrected errors will be repeated.

Correct Mistakes

I understand the patient has had
multiple visits to our Emergency
Department. However, we still need
to do a thorough H&P and treat their
pain.

The incidence of drug resistance to
that antibiotic is high, therefore
another should be considered.

Correct Mistakes
YOU DID WHAT!?!

Common Teaching Errors

Taking over the case
Not waiting long enough to listen
Lecturing the learner
Asking questions that lead too much
Asking questions that are too vague
Pushing learner too hard

Unique Challenges to Teaching

in the Emergency Department
Shift work
Rapid pace
Hectic environment
Variety of patients, students, staff
Balancing teaching and clinical tasks

General Teaching Principles

Best done in real-time

You are constantly modeling behavior for
students and residents

Consider bringing the OMP to the bedside

Teaching takes time

Every case has a teaching point

Thank you
for your
attention
Questions?
Patrick Brunett, MD, FACEP
Oregon Health & Science University
Portland, Oregon USA