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  1. 1. ACAD EMERG MED d December 2004, Vol. 11, No. 12 d www.aemj.org 1283.e1 Feedback Barbara K. Richardson, MD Abstract The emergency department provides a rich environment for performing students. Although the following examples diverse patient encounters, rapid clinical decision making, pertain to medical student education, these techniques are and opportunities to hone procedural skills. Well-prepared applicable to the education of all adult learners, including faculty can utilize this environment to teach residents and residents and colleagues. Specific examples of redirection medical students and gain institutional recognition for their and reflection are offered, and pitfalls are reviewed. incomparable role and teamwork. Giving effective feedback Suggestions for streamlining verbal and written feedback is an essential skill for all teaching faculty. Feedback is and obtaining feedback from others in a fast-paced ongoing appraisal of performance based on direct observa- environment are given. Ideas for further individual and tion aimed at changing or sustaining a behavior. Tips from group faculty development are presented. Key words: the literature and the author’s experience are reviewed to feedback; medical students; faculty development; emer- provide formats for feedback, review of objectives, and gency medicine. ACADEMIC EMERGENCY MEDICINE elements of professionalism and how to deal with poorly 2004; 11:1283. The clerkship in emergency medicine (EM) should be may continue to disrupt shift flow and jeopardize the pinnacle of student autonomy in the fourth year, patient safety. a unique opportunity to amplify clinical skills and Faculty should keep in mind that they are role medical decision making in preparation for intern- models for students and provide continuous feedback ship. Integral to this transformation from student to as they interact with patients and families, residents, physician is excellent feedback provided by faculty students, staff, and consultants. There is no better and senior residents. However, like parents in child- place to learn how to prioritize tasks and patients, rearing, faculty members are expected to perform well focus on the life threats, negotiate solutions, redirect in this role with little advance training. the expectations of the patient and families to the Ende1 defines feedback as an informed, nonevalu- possible, anticipate the complications, and efficiently ative, and objective appraisal of performance that is arrive at an appropriate disposition than the emer- aimed at improving clinical skills rather than estimat- gency department (ED). Students are great mimics ing the student’s personal worth. Feedback differs and will copy the habits of their preceptors. The from evaluation in that it is immediate and formative, ability to provide feedback and serve as a role model rather than summative, and is directed toward en- is expected of all teaching faculty members. hancing the student’s ability to modify and improve their performance over time to meet the objectives of the clerkship. Feedback is targeted to specific behav- ELEMENTS OF EFFECTIVE FEEDBACK iors the student does well and those in need of 1. Clerkship Goals and Objectives Should Be improvement. The goal is to change a poor habit or Thoroughly Understood by Students and Precep- sustain and augment effective behavior over time. To tors from the Beginning. Web sites and e-mails in be most effective, feedback should be provided on advance of formal orientation sessions can facilitate a continuous basis throughout the clerkship, at the this process. EM clerkships are generally designed as end of a case or shift, and by the site director at the subinternships with expectation of student manage- midpoint of the rotation. If the learner does not ment of a variety of acuities and presentations, re- receive realistic feedback, then the wrong behaviors quired and optional procedures, mandatory didactic sessions, recommended reading, oral or written case discussions to foster lifelong learning, and a written From the Department of Emergency Medicine, Mount Sinai Medical examination. During formal orientation, students are Center (BKR), New York, NY. informed of the requirement to actively seek feedback Received January 1, 2004; revision received March 12, 2004; during and at the conclusion of every clinical shift. accepted May 3, 2004. Providing a feedback form to students for faculty Address for correspondence: Barbara K. Richardson, MD, Depart- to complete that includes queries on a witnessed ment of Emergency Medicine, Box 1620, Mount Sinai Medical Center, One Gustave Levy Place, New York, NY. e-mail: barbara. history and physical examination, observed proce- richardson@msnyuhealth.org. dures, and a list of objectives including eliciting his- doi:10.1197/j.aem.2004.08.036 tory and physical examinations, eliciting differential
  2. 2. 1283.e2 Richardson d FEEDBACK diagnoses, ability to formulate a management plan, time to reflect on what happened and how they might interpreting laboratory test results, performing pro- do it differently the next time. cedures, and interacting with patients as well as room for a narrative of strengths and weaknesses will 6. Feedback Should Be Specific and Limited to provide a daily reminder of faculty responsibility a Few Objectives at a Time. The pace of events in the and proof of student progress in the clerkship. It ED can be challenging to seasoned preceptors and formalizes the student and faculty feedback loop and daunting to students. Feedback can be effectively identifies faculty members over time who deserve done ‘‘on the run’’ as one reviews how a case is pro- extra credit for their work or need more help with the gressing or the communication skill of a student in process. conveying only essential information and the question on a requisition or consult. Bedside supervision of 2. Students and Patients Must Have a Safe Learn- a procedure is an opportunity for verbal rehearsal in ing Environment. Provide a safe setting for students advance of the procedure, followed by midcourse to experience autonomy in data gathering and initial corrections as needed during the procedure. Often evaluation of the patient. This is readily achieved in residents or nurses are invaluable preceptors for the lower acuity areas of the ED where students are essential procedures because they have significant encouraged to be the first ‘‘physician’’ beyond the recent experience in performance. Faculty must re- triage desk. In the trauma bay and cardiac rooms, serve time at the end of the shift to review a few key students are often involved in more peripheral tasks issues and provide for reflection by the student. These or observer status; however, faculty must ensure that are not mini lectures, which have been shown to foster learning issues and performance of students and dependence, but oriented to clinical skills and specific residents are addressed once the patient has been observations. stabilized. 7. A Format for Feedback. The sandwich technique 3. Students and Preceptors Must Share Mutual of good news, corrective action, and then good news Respect. Show students the respect you would give has been promoted by some as a useful way to to any other physician. Faculty interactions with provide feedback. Others believe that overemphasis students and their patients at the bedside will on the positive may undermine appreciation for, and strongly influence a student’s choice of subspecialty. attention to, the deficiency. Depending on the person- Do not be condescending or overbearing in your ality of the student, some may hear only the negative instruction or criticism of their talents. Respect their comment and lose confidence in their ability. Regard- opinion as to the clinical status of the patient. Ask less of technique used, comments should be specific, them to identify any areas of uncertainty. Underscore not personal (e.g., ‘‘ I noted you had trouble with the the importance of honesty in all clinical interactions. ABG’’ rather than ‘‘You are completely incompetent at Give them your undivided attention during their blood gases!’’). presentations; resist the urge to interrupt frequently. 8. Label Feedback. Unless clearly stated, students 4. Feedback Should Be Timely. Constructive feed- will fail to recognize feedback and you will not be back prevents poor first efforts from becoming bad recognized for your effort. Clearly identify your habits. Reserve corrective actions whenever possible comments as constructive feedback on the perfor- for private conversations. Global deficiencies in a stu- mance for that shift.2 dent should be brought early to the attention of the clerkship director. 9. Dealing with a Student’s Response to Feedback. Students with repeated problems should be inter- 5. Dealing with Poor Clinical Skills. A student may viewed in private. Students will be less defensive if be an exhaustive reporter of medical data but unable the site or clerkship director explores the student’s to organize the pertinent information for a concise perception of what is wrong and how he or she thinks oral presentation or chart note. Systematizing the it could be improved. Students are often relieved to approach driven by the chief complaint will improve learn that they can reform and still complete the future performance. Students may lack confidence in course in a satisfactory manner. Misperceptions can their clinical examination. Findings should be re- be dispelled. Students rotating through the ED post- viewed at bedside. Offer to demonstrate findings and match to their subspecialty of choice may have a lack procedures. More advanced students may require of motivation. Savvy preceptors should rejoice in their help with task prioritization or selecting evidence- success but underscore the potential value of the based therapeutic plans. It is useful to ask what they clerkship (makes the internship less daunting) and would like to know/see, etc. Students exhibiting poor the consequences of not achieving the minimum interpersonal skills with nurses or patients need objectives (failure to graduate on time). Serious in- a private session with the preceptor to allow them terpersonal difficulties are unlikely to be a new issue
  3. 3. ACAD EMERG MED d December 2004, Vol. 11, No. 12 d www.aemj.org 1283.e3 by the fourth year of medical school. Discussions with d Give immediate feedback at the end of a shift or the dean’s office may yield appropriate corrective patient interaction, not just at specified times. actions. Students whose work appears to degenerate d Discuss criticisms with a student before writing toward the end of the clerkship may have a legitimate them into a final evaluation. reason, such as a family emergency or serious per- d Initiate feedback before students have to ask for it. sonal health issue. Upon discovery, students will still Feedback from faculty and senior residents will be required to complete the clerkship, albeit in a more differ in emphasis and rating but can provide valu- relaxed time frame. able insight into student performance. Residents tend to rate students higher than faculty and focus on team dynamics, work ethic, and procedural skills. Faculty 10. Legal and Illegal Criticisms. Limit feedback to more often comment on fund of knowledge, reason- remediable behavior. Preceptors who find themselves ing, and communication skills.6,7 very angry with a student should take a five-minute Faculty skills in feedback technique can be de- timeout before providing criticism. By first soliciting veloped in small group discussions, which include feedback from the student, a positive message is clerkship objectives, teaching tools, videotapes, and conveyed that both student and preceptor can im- critiqued role play.8 Starting with a needs assessment, prove their communication, performance, etc.3 Re- a program can be designed using lecture format, small member that students may be as stressed as faculty group discussions, and even standardized students to during a particularly busy shift. Taking time out after permit faculty to try out techniques and obtain valu- your shift for a brief meal break or the next day to able feedback from colleagues and mentors in a pro- review some of the salient points that could not be tected environment. covered in real time will strengthen the bond with the Residency directors in EM and other disciplines student and heighten your credibility. share the same interest in faculty development and may invite national speakers with expertise in this area. Departments or institutes of medical education FACULTY DEVELOPMENT in medical schools can create interdisciplinary di- Labeling all students as ‘‘phenomenal’’ may make you dactic and experiential sessions that focus on feed- a popular preceptor but does little to assist the student back and other key issues in teaching. Faculty with in identifying areas of weakness or help the site interest in teaching fellowships should consider director to determine whether the objectives are being CORD’s Navigating the Academic Waters program, met. Indirect comments, in an attempt to preserve the medical education programs (such as the one-month student’s self-esteem or facilitate the active learning programs at Stanford University), Association of process, may result in failure of the student to American Medical Colleges or Harvard Macy fellow- recognize a medical error as an error.4 Faculty fears ships, or an advanced degree program (such as the of student reprisal, failure to recruit students to the master’s in education offered at the University of specialty, or even litigation are unfounded if feedback Illinois). is respectful and based on objective observation. Nonetheless, faculty may be unwilling to discuss HELPFUL HINTS AND EXAMPLES OF marginal students on paper. Group meetings at FEEDBACK regular intervals with faculty and residents who supervise students are more likely to uncover serious 1. Student self-reflection.9 ‘‘What went well?’’ problems. Encourage calls from faculty if there are ‘‘What do you need to work on?’’ Solicit feedback concerns. Clerkship and site directors will also find it from the student on their performance during valuable to observe faculty–student interactions on an a particular encounter or shift. Although many unannounced basis. students will tend to be overcritical, it gives the Kernan et al.5 surveyed third-year students to faculty member insight into weaknesses the stu- identify faculty behaviors that facilitated learning. dent is aware of as well as those the student has Under the domain of feedback, 86%–97% of respond- not recognized. The faculty member can then ents agreed with the following: suggest specifics on how to improve through reading, study, skills, or practice.8 d Read notes promptly in the rotation to comment 2. Make specific observations. Pangaro10 developed regarding form, content, and length. the R-I-M-E (Reporter–Interpreter–Manager–Edu- d Do not stop at global criticism. Be specific and cator) construct to identify specific milestones in directive, citing alternative ways of doing the student progress. Some examples follow. pertinent skill. d Tell students when they are doing something well. d When an error is made, tell how to do it right; Feedback on Student as Reporter. ‘‘With Mrs. when they do, compliment them. Smith, I thought you were pressured to complete
  4. 4. 1284.e4 Richardson d FEEDBACK a thorough history on chest pain, which is important, not responded, what would your next step be? What but you didn’t give her much time to tell you about will be important in the education of your patient?’’ the quality and character of the pain. How might that ‘‘You have arrived at the most likely diagnosis. In change your index of suspicion for acute coronary emergency medicine, we must often make decisions syndrome in this patient?’’ based on a limited data set and time with the patient. ‘‘I have observed that you do not routinely inquire Abdominal pain is a frequent presenting complaint and about HIV status in patients with upper respiratory it is not possible or appropriate to perform exhaustive complaints. If you agree that knowledge of HIV status workups on every patient. What danger signs will you will affect your differential and treatment, where discuss with your patient to ensure prompt return if might be a good place to work this into your history a more serious condition is unfolding?’’ taking?’’ ‘‘Your explanation to the asthma patient on how to (Session following a corrective action) ‘‘Your effort avoid triggers and the proper way to use inhalers is to make your presentation and chart more problem likely to improve patient well being and reduce oriented has paid off! Your ability to focus on the further ED visits. You were smart to ask the patient problem(s) and be concise in documentation will be to return a demonstration and describe her under- a real timesaver during your internship and much standing of the discharge instructions.’’ appreciated by your colleagues and consultants.’’ 3. One goal of the clerkship is to improve efficiency Feedback on Student as Interpreter. ‘‘Your elder and focus in patient evaluation. A brief preview of patient presents with a history of heart failure and the chief complaint and vital signs with the bradycardia. Can you review your interpretation of student in advance of the patient evaluation will the ECG and electrolytes again? Great! You have identify those students who will need earlier correctly identified a ventricular escape rhythm and supervision and those patients who will need hypokalemia. How might they be related? What else a team approach. Students are granted some is in your differential?’’ autonomy with stable patients commensurate ‘‘You have done an admirable job on the history and with their experience. Students benefit most physical examination in this patient with acute head- when faculty seek their input and confirm ques- ache. In addition to what you believe to be the most tions or findings at the bedside, leaving students in likely diagnosis, what are others, which you must control of the case. Patients are usually tolerant of consider, in order not to miss a grave condition? What some delays that are inherent in this approach. might be a good source in which to find this in- However, faculty must assume control of a case formation?’’ whenever there is potential for harm to a patient.11 4. Interrater reliability will increase when multiple Feedback on Student as Patient Manager and encounters are included.12 Ten to 16 or more Educator. ‘‘Clarity in order writing is an important eight- to 12-hour shifts are easily incorporated way to reduce medical errors. The nursing staff ex- into a three- to four-week clerkship. Students may pects certain conventions. Let’s review your orders for get more valuable feedback if they work with the Mr. Jones. The nurses are looking for drug, dose, same faculty member for the majority of shifts. In route, and frequency.What source did you use to many departments, this is not possible due to learn about this drug and decide upon the dose?’’ conflicting demands on faculty and the desire to ‘‘You have presented two patients today with expose students to a variety of teaching styles. It is possible fractures. How might you reduce their always preferable to have a student present to the discomfort in X-ray? Do you need a diagnosis before same faculty member on a given shift. Students on administering pain medications? What would be ‘‘audition’’ electives should work several shifts appropriate? Would you like to review the steps with at least one member of the residency selec- before making a splint for this patient?’’ tion committee. The site or clerkship director (After concern was voiced by the RN chaperone) determines which scenario works best in view of ‘‘Can you walk me through the techniques you use to the number of students in a particular block. prepare a female patient for a pelvic exam? Would 5. Many faculty members believe that professional- you like me to demonstrate how I do it?’’ ism is the most important aspect of student ‘‘I notice that the alcoholic patient you are inter- assessment. Faculty members are encouraged to viewing is becoming quite agitated. It is a challenge to comment on maturity, responsibility, honesty, and manage patients who are potentially disruptive. Let’s respect for patients and staff demonstrated or step back for a moment and review what you know abrogated by the students. Do not permit or model and what you think might be going on.perhaps you inappropriate negative comments about recidivist should use a different approach.’’ or other challenging patients. Labeling can lead to ‘‘You did a great job recognizing and alleviating the gross negligence in patient care. Pejorative docu- airway obstruction in your patient. Had the patient mentation is an invitation to litigation.
  5. 5. ACAD EMERG MED d December 2004, Vol. 11, No. 12 d www.aemj.org 1283.e5 6. Focus feedback on areas the student can control. and promote feedback on patient outcomes so essen- Primary objectives to practice in EM include the tial to our personal performance improvement. ability to establish and use a limited data set Clerkship directors are encouraged to explore quickly, prioritize tasks, engage in conservative resources within and beyond their own institution to diagnostic reasoning, and manage more than one assist in the development of excellent preceptors. patient simultaneously. Negative comments on Regular meetings between sites and visits by the speech defects or language difficulties are off limits. clerkship director to each site will help to maintain 7. Limit feedback to a few important observations. Do consistency and collaboration and reinforce the criti- not attempt to create the quintessential EM student cal role of site faculty in the training of students. in one session. Respect the fact that all students can Documentation of successful efforts in teaching stu- gain enormous value from your teaching and this dents is critical to institutional recognition and in- rotation. Accept that not all of them wish to emulate dividual faculty advancement. you and become emergency physicians! 8. Be receptive to suggestions from students about how to improve feedback. At our institution, References students are required to submit anonymous eval- 1. Ende J. Feedback in clinical medical education. JAMA. 1983; uations of the clerkship and faculty interactions in 250:777–81. order to obtain their grades. There are electronic 2. Albritton TA. Feedback. In: Fincher RE (ed). Guidebook for Clerkship Directors. Washington, DC: Association of American systems that facilitate this labor-intensive work. Medical Colleges, 2000, pp 135–8. Evaluations are reviewed by the site directors and 3. Weinholtz D, Edwards J. Providing feedback. In: Mumford L returned to individual preceptors at intervals to (ed). Teaching During Rounds: A Handbook for Attending preserve confidentiality. Just as a single negative Physicians and Residents. Baltimore: Johns Hopkins Press, comment is cause for concern regarding a student, 1992, pp 85–93. several negative comments about a faculty member 4. Ende J, Pomerantz A, Erickson F. Preceptors’ strategies for correcting residents in an ambulatory care medicine setting: should be addressed through a private conference a qualitative analysis. Acad Med. 1995; 70:224–9. or personalized faculty development session. 5. Kernan WN, Lee MY, Stone SL, Freudigman KA, O’Connor PG. Effective teaching for preceptors of ambulatory care: a survey of medical students. Am J Med. 2000; 108:499–502. CLOSING COMMENTS 6. Metheny WP. Limitations of physician ratings in the assessment of student clinical performance in an obstetrics and Aside from being required by the Liaison Committee gynecology clerkship. Obstet Gynecol. 1991; 78:136–41. on Medical Education, feedback is an integral part of 7. Hull AL. Medical student performance: a comparison of house our role as faculty and clerkship directors. For some of officer and attending staff as evaluators. Eval Health Prof. us with excellent observational and interpersonal 1982; 5:87–94. 8. Keenan JM, Seim HC, Bland CJ, Altemeier TM. A workshop skills, this is an easy transition. For the rest, thor- program to train volunteer community preceptors. Acad Med. oughly reviewing the goals of the clerkship, spending 1990; 65:46–7. time directly observing the students in action, and 9. Woolliscroft JO, TenHaken J, Smith J, Calhoun JG. Medical practicing active listening will produce better feed- students’ clinical self-assessments: comparisons with external measures of performance and the students’ self-assessment of back and enhance performance while maintaining overall performance and effort. Acad Med. 1993; 68:285–94. student motivation and self-confidence. 10. Pangaro L. A new vocabulary and other innovations to The successful clerkship will dramatically advance improve descriptive in-training evaluations. Acad Med. the student’s ability to apply clinical skills and prac- 1999; 74:1203–7. tice medical decision making as well as appreciate 11. Lesky LG, Borkan SC. Strategies to improve teaching in the challenges in EM. As students graduate to higher the ambulatory medicine setting. Arch Intern Med. 1990; 150:2133–7. domains, it is hoped that positive bonding with 12. Elnicki DM, Ainsworth MA. Evaluating the internal medicine ED faculty during the clerkship should inculcate re- clerkship: a Clerkship Directors in Internal Medicine spect for our work, encourage collegial interactions, commentary. Am J Med. 1994; 97:I–VII.

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