Review of effective techniques for providing feedback. Considering stakes, situational complexity, trainee resistance, and mentor skill when preparing for giving feedback.

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PROVIDING CONSTRUCTIVE FEEDBACK TO
RESIDENTS: PRACTICING GOOD PRACTICES
HARRIET W. HOPF, MD
PROFESSOR OF ANESTHESIOLOGY
ADJUNCT PROFESSOR OF BIOMEDICAL ENGINEERING
UNIVERSITY OF UTAH
@HarrietHopfMD

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DISCLOSURES
• I have no disclosures

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DISCLOSURES
• I have no disclosures
EXCEPT

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DISCLOSURES
• I have no disclosures
EXCEPT
• I struggle providing constructive feedback

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OBJECTIVES
• Identify areas to improve feedback skills in a
clinical context
• Learn new techniques & approaches for providing
authentic and constructive feedback
• Rehearse and debrief providing constructive
feedback

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EFFECTIVE FEEDBACK
• Effective clinical teaching requires ability to:
– Provide constructive feedback that is:
• Timely
• Kind
• Aimed at improving performance
– Engage in difficult conversations
– Manage interpersonal conflict and conflicting
communication styles

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RESOURCES
• Hewson MG, Little ML: Giving feedback in
medical education: verification of
recommended techniques. J Gen Intern Med
1998; 13:111–6
• Ramani S, Krackov SK: Twelve tips for giving
feedback effectively in the clinical environment.
Med Teach 2012; 34:787–91

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FEEDBACK COMPLEXITY MATRIX
Situational
contributions
Trainee characteristics
Mentor characteristics
Best Practices work!
Bad news / hard decision
Concern for trainee
TraineeResistance
History
Complexity
Escalation
Recurrence
Lack of resolution
HighLow
Stakes
Routine High

9. © U N I V E R S I T Y O F U T A H
FEEDBACK COMPLEXITY MATRIX
Situational
contributions
Trainee characteristics
Mentor characteristics
Best Practices work!
Bad news / hard decision
Concern for trainee
TraineeResistance
History
Complexity
Escalation
Recurrence
Lack of resolution
HighLow
Stakes
Routine High

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FEEDBACK VS. EVALUATION
• Feedback: Formative / Non-Judgmental
– Verbal: In person on the same day
– Written: Ideally within a short time period
• Evaluation: Summative / Judgmental
– Verbal: At the end of a rotation, in person
– Written: At the end of a rotation, usually collated from
all feedback

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FEEDBACK SHOULD BE:
• Formative and constructive
• Non-judgmental
• Brief
• Timely
• In private / confidential
• Focused on behaviors
• Focused on things the trainee can act on
Great job!
He is unprofessional.
Needs to read more.

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APPROACHES
• (Feedback Sandwich)
• Ask - Tell – Ask - Tell
• Formal rubric
• Situation – Behavior - Impact

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FEEDBACK SANDWICH
• Meat layered between
two pieces of bread
– Bread = praise
– Meat = constructive
criticism
• Overuse may reduce trust
• Positives may drown out
negatives
• Other approaches more
effective
https://www.linkedin.com/pulse/stop-serving-feedback-sandwich-adam-grant

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ASK-TELL-ASK-TELL
• Ask: “What went well?”
• Tell:
– Your observations: what trainee names and other areas
• Ask: “What could be improved?”
• Tell:
– Your observations, based in behaviors / what they did
• “You did not seem to notice the oxygen saturation decreasing.”
• NOT: “You are dangerous.” or “You don’t care about your
patient.”
• Follow up recommendations: actions to improve in
the future
http://paeaonline.org/wp-content/uploads/2017/02/Ask-Tell-Ask-Feedback-Model.pdf

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FORMAL RUBRIC
Objectives: Anesthesia Induction
1. Demonstrate a safe and elegant anesthetic induction.
2. Defend the choice of agents and procedures for the particular patient
based on evidence.
3. Articulate means to implement alternate approaches in future patients.
Grading criteria description CA-1 CA-2 CA-3
In OR by 0730 OR not rate limiting step
AND cognizant of patient safety issues
___/5 ___/5 ___/5
Explicit plan for case including preparation for
likely events and complications with follow
through
___/30 ___/22 ___/15
Communication with surgeon(s) and nurse(s)
regarding specifics of case
___/25 ___/20 ___/15
Smooth transition from into room to induction ___/5 ___/5 ___/5
Appropriate preparation of the patient prior to
induction including safety and patient comfort
___7 ___/5 ___/5
Skill with safe and efficient airway
management
___/5 ___/8 ___/10
Vital signs within 20% of baseline OR
Appropriate response to changes
___/5 ___/8 ___/10
Awareness and appropriate attention to
contamination
___/6 ___/7 ___/8
Adaptation to changing circumstances ___/5 ___/7 ___/8
Efficient transition to surgeon ___/5 ___/8 ___/10
Prepared for positioning with lines/monitors ___/2 ___/5 ___/9
TOTAL __/100 ___/100 ___/100
https://ctle.utah.edu/

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SITUATION-BEHAVIOR-IMPACT
• Situation
– Anchored in time and place
• Behavior
– Observable action
• Impact
– Thoughts, feelings, and/or actions that resulted from behaviors
• Avoid attributing feelings and judgment to the trainee
– “You were rude and disrespectful”
• Instead, focus on feelings/values of the person impacted
– “When you answered the phone call and kept looking at your watch during our meeting, I felt like a low
priority and disrespected.”
– Good for professionalism, communication, attitudes/behaviors
https://www.mindtools.com/blog/corporate/wp-content/uploads/sites/2/2014/05/SBI-Feedback-Tool.pdf

17. © U N I V E R S I T Y O F U T A H
FEEDBACK COMPLEXITY MATRIX
Situational
contributions
Trainee characteristics
Mentor characteristics
Best Practices work!
Bad news / hard decision
Concern for trainee
TraineeResistance
History
Complexity
Escalation
Recurrence
Lack of resolution
HighLow
Stakes
Routine High

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GRAPHING FEEDBACK
Stakes
Trainee Resistance
High
High

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SCENARIO 1
You are working in clinic with a resident you have never worked
with before. As you are co-signing her clinic notes at home, you
realize her notes are insufficiently detailed such that her
documentation now seems to be on the verge of compromising
patient care.
You have asked to meet with her to discuss documentation.

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SCENARIO 2
You have noticed that, over the past year, your resident has been writing clinical notes
that are insufficiently detailed such that her documentation now seems to be on the
verge of compromising patient care. She feels that the approach she takes to
documentation is efficient and works well for her. You have tried to provide her with
feedback several times over the past year, but she becomes increasingly defensive
each time and consistently challenges the need for a change in her approach to her
clinical documentation.
You are now dreading what will be your 5th meeting with her this year to address this
issue.