Giving and Receiving Feedback
By Bret Barrier, MD, Associate Professor, University of Missouri
You are a diligent and caring medical educator. You can recite the elements of good feedback from memory: timely, specific, objective, non-judgmental, actionable, collaborative. But still, feedback is difficult. When a case or clinical encounter is over, you think to yourself, “I should give my learner feedback.” But for some reason, especially when events proceeded smoothly, it is difficult to identify the content of the feedback. It is particularly difficult to provide feedback to medical students when your priority is felt to be on teaching residents or fellows.
Why is giving feedback so difficult?
If you ask a group of medical educators to be candid, many will tell you that they avoid the responsibility of providing feedback. (1) This is not surprising, and is corroborated by the results of a published resident survey of feedback practices in which 80% of medicine residents reported “never” or “infrequently” receiving feedback from attending physicians. (2) I would suggest that, if this can be the case with residents, then medical student feedback is on equal or worse footing. But why would those of us who have committed our lives to medical education fail to provide such a vital learning experience? Let’s examine medical student feedback.
Good feedback hinges on good observation
You’ve heard the old adage, “Garbage in, garbage out.” Simple logic tells us that it is impossible for someone to provide feedback if they haven’t observed the learner. Let me ask you a few important questions. How often do you pay attention to a medical student’s interaction with patients in your clinical setting? How often does a student examine a patient in your presence, or obtain a history, or present the patient history and physical directly to you? It seems so simple, but if you are not studying the student, you will have no material on which to base your feedback.
If you do resolve to more closely observe a medical student’s behavior in a clinical setting, how does this translate into effective (especially written) feedback? Here is an exercise. Buy a deck of 3×5 cards and keep some in your pocket. When you identify a student on your service, ask his or her name and write it on the top of the card. Then, make a point of observing the student’s behavior.
- Do you observe the student obtain a history from a patient?
- Examine a patient?
- Deliver a placenta?
- Interpret laboratory abnormalities?
Describe the behavior you observe on the card, and keep it simple. “Delivered a placenta” or, “discussed pre-eclampsia labs.” Now, deconstruct the event and write down one point that could be improved or corrected. “Performed fundal rather than anterior uterine massage” or “Did not understand the pathophysiology of hemoconcentration.” Talk to the student about it. Ask the student what he or she thinks could be improved and share your observations. Offer a better way to perform uterine massage or teach the student about hemoconcentration. Ask the student what he or she has learned and make a final note on the card, documenting the outcome or action recommended. Revel in your feedback success! Keep the card, and use it to prompt your memory when you interact with the student again, or as written notes for documenting your electronic evaluation.
If you can get into the habit of observing medical students more carefully and framing feedback events by making notes, you have won most of the battle! But perhaps you are still feeling overwhelmed at the thought of getting started. Why? As clinical faculty members move further from their own undergraduate medical training, they lose perspective about what a medical student should know or not know. What events should you observe and offer feedback on? Will you overwhelm the student if you expect him or her to understand the nuances of UA Doppler waveforms? Will you bore the student if you ask him or her to describe the cardinal movements of labor? It might help if you learn and rely on a set of developmentally appropriate teaching scripts to guide your interactions with students.
Exploit the value of teaching scripts
What are teaching scripts? Script theory is a concept originating from the framework of cognitive psychology during artificial intelligence research and development. In its simplest form, a “script” (or schema) is an abstract cognitive structure that arises from repeated real-world experiences that cause information to be organized in a specific way. (3) That is a bit abstract. But don’t worry, you already know a teaching script when you see it. Think back to your much-regarded surgical attending in residency or fellowship. What did he or she ask EVERY TIME you entered the broad ligament during a hysterectomy? “Where is the ureter located? Medial leaf. Good. Show it to me. Good. Now, if the pelvis were socked in, what landmarks would you use to find the ureter?” And so on. It was predictable. Do an abdominal hyst, open the broad, and here comes the script. Different attending surgeons seemed to have their own “pet” scripts, didn’t they?
Teaching scripts are an important tool for evaluating learners, because they simplify and standardize the information-gathering process. Scripts make the world predictable, providing you a point of reference by which to compare knowledge or performance across many learners in a way that is predictable. As stated by Charlin, et al. (3): Expectations and actions embedded in scripts allow subjects to make predictions about features that may or may not be encountered in a situation, to check these features in order to adequately interpret (classify) the situation, and to act appropriately. So a script frames a medical student teaching moment in a way that puts it against a familiar backdrop, making it easier to evaluate the student compared with past students. And that provides information that can guide you in providing effective feedback.
Choose a couple of useful scripts
How does one get started choosing a script to use with medical students? Try this. Open up the APGO Medical Student Educational Objectives and choose an objective that is common to your workflow when medical students are around. Let’s pick “Determine Gestational Age.” Now, when you are on L&D, and a student presents a triage patient to you or to a resident, listen to the presentation carefully. At some point ask the student, “What did you say is the patient’s gestational age?” Perhaps the reply is “39 weeks.” You’ll respond, “How do you know?” And now the script is running. Over time, you will hear hundreds of students offer accurate or inaccurate explanations of how to determine an accurate gestational age, and it will give you a comfortable means of assessing student knowledge.
Lack of knowledge may prompt a teaching script, with questions like, for example, “When were Shaquille O’Neal and I pretty much the same size, early or late in gestation?” This is intended to reinforce that earlier ultrasounds provide a more accurate estimate of gestational age. Yes, your residents may groan when you mention you and Shaq in utero yet again. But, so did you when your favorite attending launched into his well-worn script about incision size and safe operative exposure. And to this day, you don’t cheat yourself or the patient with a suboptimal incision during a critical case.
Once you have a small arsenal of teaching scripts, go to work! Provide some feedback! Step out in faith. Suspend disbelief. You can do it! After you invest the startup energy, it will become easy and enjoyable rather than burdensome.
Final words
Provision of timely feedback for medical students is not merely an occupational duty, but a solemn responsibility, rooted in the ethical principles of justice and beneficence. We often don’t appreciate the impact we have in so doing: impact on the student’s professional formation, their future career (by documenting written feedback for their MSPE), and on the health and well-being of scores of their future patients. I encourage you to take the APGO Medical Student Educational Objectives in hand, and develop at least three teaching scripts. Grab some 3×5 cards. Hunt down some medical students and give them your attention. The feedback will come easier the more you use and refine these techniques.
- Ende J. Feedback in clinical medical education. JAMA 1983;250(6):777-81.
- Isaacson JH, Posk LK, Litaker DG, Halperin AK. Resident perceptions of the evaluation process. Society of General Internal Medicine. J Gen Intern Med. 1995;10(suppl):89.
- Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ 2007;41(12):1178-84.