PGY 1 Retreat
6/16/15




Thinking about education
How to be a good ward resident- small
groups with the Chiefs
Intern class reflection
Changes for next year; administrative
issues; misc…………..
But first………

Working alone, list the top 10 drugs
prescribed in the United States in 2015
in terms of the number of monthly
perscriptions…..

Now, repeat this exercise, working in
small groups with the people sitting
near you……..
Number of monthly
perescriptions
1.Synthroid, 22.6 million
2.Crestor, 22.5 million
3.Nexium, 18.6 million
4.Ventolin HFA, 17.5 million
5.Advair Diskus, 15.0 million
6. Diovan, 11.4 million
7. Lantus 10.1 million
8. Cymbalta, 10.0 million
9.Vyvanse, 10.0 million
10. Lyrica, 9.6 million

As a resident- your job is to foster a
positive team environment


Emotional intelligence
Working in teams
Giving Feedback


Keith Armitage
Case Western Reserve University
Giving Feedback

Case scenarios
Introduction




Defining feedback
The importance of feedback
Examples of good and bad feedback
Techniques for giving feedback



Feedback is not criticism!!
You are a coach
The ability to reflect……an essential
part of modern medical practice
Introduction


Most feedback in medical education is
self feedback based on the
observation of self and others.
Depends on the ability of the learner to
give self feedback.


Most good internists have this ability.
Optimally self feedback is confirmed and
augmented by external feedback.
Defining feedback


Rocket science model
“Feedback in the control of a system
by reinserting into the system the
results of its performance……if the
information is able to change the
general method and performance, we
have a process which may be called
learning.”

Humans are more complex; clinical
performance is more complicated than
rocket science
Defining feedback

Formative





Summative




Non-judgmental; presenting information, not
judgmental
Rocket science model
Neutral, not “good” vs. “bad”
“coach”
After the fact, sum of performance, grade
“evaluation,” compared to peers
“judge”
vs. encouragement
The importance of giving feedback

Obligation in all training situations






Learner feels adrift without feedback
Misinterpretation of nonspecific signals
Bi-directional!
Role of providing information/corrective
action
Correction of mistakes in the clinical setting
“Vanishing Feedback”

Monthly faculty reminders
Examples of “good” and “bad” feedback

Good


Timely, specific, nonjudgmental, devoid of
emotion, private/appropriate setting, given in
climate of trust, diagnostic/useful, goal
oriented, focused on performance, not
personal, supportive, objective, occurrence
based, useful
Bad

Vague, public, given in anger, non-timely,
personal, “punishment,”
Examples of good and bad feedback, cont


“Your differential diagnosis was O.K.,
but you might have also considered
tuberculosis.”
“Your differential diagnosis was
poor/inadequate.”
Techniques for Giving
Feedback

The sandwich


Beginning and ending with positive
observations
Positive feedback- corrective feedbackpositive feedback
Techniques for Giving Feedback,
cont.

The Club Sandwich





Reinforce success
Corrective feedback
Affirmation in your belief that the learner
can move forward
Plans for moving forward
Commitment to support them in their
plans
The Club Sandwich, cont.





I am impressed that you know your patients
labs so well
The critical next step is interpreting the labs;
for instance, describe the anemia as
microcytic, and discuss what this means
I am confident that you can take this next
step
Do you have ideas about how to do
accomplish this?
I would be happy to help work with you on
this issue
Techniques for Giving Feedback,
cont.
Micro feedback
Small opportunities with students as they
arise
 Capitalize on the moment

Catch them doing something well


Use a nonjudgmental rule statement


Good history- he was a tough guy to talk to
When patient come in with so and so, it is important
to ask about
Give the learn a chance to re do their
performance

Why don’t you go back and ask about
Techniques for Giving Feedback, cont.



The “tell me how you think you are
doing.”
Take advantage of situations as they
arise in the clinical setting.
Focused on goals


“Do you want to be the best intern/doctor you
could be?”
Turn “negative” feedback into challenge
Techniques for Giving Feedback, cont.



Assess learners level of receptivity to
feedback
Encourage learners to ask for feedback
Test your hypothesis about what the
problem is



Diagnosing your learners
Avoid overloading
Follow-up is key
Impediments to giving
feedback

Time




Inadequate observations
Time to meet
Concern over popularity
“Not wanting to hurt feelings,” damage
student teacher relationship
Techniques for Giving Feedback,
cont.

Avoid focusing on personality traits,
unless they affect clinical care
Impediments to giving
feedback

Past experiences that were
emotionally difficult; fear that feedback
will elicit an emotional reaction

Concerns about the impact of feedback
leads to no feedback at all
Impediments to giving
feedback

Humiliation


External emotion that can be avoided if the
teacher provides nonjudgmental feedback
Embarrassment


Internal emotion, sometimes can’t be
avoided, may be motivational
Dealing with tears/anger

Emphasize your willingness to help and their
ability to improve
Now that you are a believer in
feedback

Feedback is bi-directional



Please take evaluation of your attendings seriously
Cumulative data with comments is returned to
attendings
Promotion and tenure
Armitage’s general hints for dealing with
feedback/administrative situations


Never begin a conversation in anger or
assuming the other person is at fault
If you make the issue patient care, you
will (almost) always win


Always make it patient centered
Kick it upstairs
Mindfulness


Paying attention, on purpose, to one’s
own mental and physical process
during everyday tasks to act with
clarity and insight
(the first thing you do at a code…….)
Habits of Mindful Practitioners

Attentive observation


Critical Curiosity


Processing….
Tolerating and ‘enjoying’ being wrong
Presence




Control of anxiety
Egoless focus on tasks
Tolerating contradictory ideas
Compassion based upon insight
Mindfulness




Understanding your reaction to
patients
Incorporating ethics into decision
making
Reflection…..!
Being purposely mindful
And Finally- another10 minutes on
education


Models of learning
1 minute preceptor
RIME




Reporter
Interpreter
Manager
Educator

Diagnosing the
learner….
The One Minute Preceptor




What do you think?
Why do you think that/what else did
you consider
What I am thinking
Where do we go from here- positive
feedback and next steps
Teaching the 4 C’s of
Effective Oral
Presentations on Work
Rounds
The 4 C’s of effective oral
presentation
will only be successful . . .
. . . if the resident sets the
expectations at the start of a
rotation
Remember the 4 C’s

COHERENT

CONCISE

COMPLETE

COMPELLING
COHERENT





Introduction (one sentence!)
Subjective
Vital signs
I/O’s
Physical Exam (pertinent)
New study results

Review of chart (nurses notes, etc)
Assessment and Plan:

CONCISE ( 1-2 minutes)

Essential

Pertinent

Uncluttered

The student should be . . . brief and
lucid

The student should speak . . . crisply
and clearly without notes
The 4 C’s algorithm will be
successful only with

APPROPRIATE
FEEDBACK

“Without feedback,
mistakes go
uncorrected, good
performance is not
reinforced, and
clinical competence
is achieved
empirically or not at
all”
- Jack Ende, M.D.

Four steps of clinical teaching




Needs assessment
Teaching to the learner
Feedback
Reinforcement
Teaching Clinical Reasoning
“On the Fly”
Key Points to Remember

Teach while you work


Clinical reasoning is most effectively
taught as you care for patients together,
not in a lecture hall or conference room
Live what you teach

If you don’t “role model” sound clinical
reasoning as you discuss all your
patients, the students won’t think it’s
really important
Bottom Line

Teach as you work and live what you
teach!

Be systematic and think out loud

What are the problems? Foreground and
background.

What’s the differential? Focus on likelies
and high stakes possibles.

Let your differential drive work-up and
management
Long term career goals…




Use elective time for scholarly projects
Work with clinical mentors
Meet with your PD to discuss…..
If you are interested in subspecialty
training- apply at end of PGY2 year..