1. Free Writing Prompt #3 You will have 5 minutes to offer your thoughts about this question. Keep the pen (or pencil) moving. The idea is to access your immediate ideas and put them directly on the page. Your hand should be moving at all times, even if you repeat yourself. Do not worry about spelling, grammar or punctuation. Please feel free to use both sides of the paper. From your own experiences with remediating students, what behaviors, actions, etc… have you found effective?

2. This Trainee Is Terrible: How to Help the Struggling Learner Calvin Chou, MD, PhD, FAACH University of California, San Francisco

3. Creative Commons License Attribution-NonCommercial-Share Alike 3.0 Unported You are free: to Share — to copy, distribute and transmit the work to Remix — to adapt the work Under the following conditions: Attribution. You must give the original authors credit (but not in any way that suggests that they endorse you or your use of the work). Noncommercial. You may not use this work for commercial purposes. Share Alike. If you alter, transform, or build upon this work, you may distribute the resulting work only under a license identical to this one. See http://creativecommons.org/licenses/by-nc-sa/3.0/ for full license.http://creativecommons.org/licenses/by-nc-sa/3.0/

4. Disclosure Royalties from book sales go directly to American Academy on Communication in Healthcare

5. Why are you here? Because you do lots of remediation and want to validate your approach Because you are interested in doing more, learning more Because you’re just kind of curious Because you were forced to be here Because all of my learners are terrible

6. Road Map Definitions and Framing Feedback

8. Remediation in medical education Facilitating a correction for trainees who started out on the journey toward becoming an excellent health professional but have moved off course

10. ’T’T

12. The Importance of Perspective Cone in the box

13. Ladder of Inference I take actions based on my beliefs I interpret the data, draw conclusions, and formulate beliefs I select “data” – my observations Observable “data”

14. For the struggling learner I roll my eyes and cut off the student’s presentation (after 5 seconds) He doesn’t know what he is doing! Family history should always precede social history The student’s presentation did not follow the usual H&P structure

15. Anna Mid 3 rd year student Downcast eyes during rounds, little interactivity with team, checks cell phone a lot Presentations lackluster

17. INFORMATION OVERLOAD

19. UM

21. TZLD

23. KXCEJO

25. AVCYISEH

27. LBFKQRMAUX

29. TQBFDNTJBFSR

31. ZQECTBUMONRV

33. UM (2) TZLD (4) KXCEJO (6) AVCYISEH (8) LBFKQRMAUX (10) TQBFDNTJBFSR (12) ZQECTBUMONRV (12)

34. Memory model Sensory Memory Sensory Memory Long Term Memory Long Term Memory Working Memory Working Memory

35. “Cognitive Load” Automate tasks Develop internal scripts

36. Skills in the ART of Delivering Effective Feedback Calvin Chou, MD, PhD UCSF Department of Medicine

38. Quotation Without feedback, mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved incidentally or not at all. Ende, JAMA 1983

39. Case You are supervising Ahmed, a third-year student on internal medicine who is generally average student but forgets occasional details. In one patient admitted with dyspnea and anemia, he did not report if a work-up for anemia was done.

40. Scenario 1 You say only positive things to Ahmed. In your evaluation, you write: “student was terrific.”

41. Scenario 2 You say only positive things to Ahmed. In your evaluation, you write: “student did fine but could have been more detail-oriented during presentations.”

42. Scenario 3 After Ahmed presents the patient with anemia, you say: “You should have reported the results of the anemia work-up on this patient.”

43. Scenario 4 After Ahmed presents this patient, you say: “Ahmed, I liked how you went through the differential diagnosis for the patient’s shortness of breath. You should have talked about the patient’s anemia work-up, if it was done. But overall it was great.”

44. The sandwich

45. Goals Define “feedback” in medical education Assimilate literature on feedback into an approach to giving feedback Describe a method of nonjudgmental delivery of feedback Rehearse a feedback encounter

46. Definition and Facts Feedback: specific, nonjudgmental information comparing a trainee’s performance with a standard, given with intent to improve performance Fact: Feedback is always being given, consciously or unconsciously, skillfully or carelessly Suggestion: Feedback is an expression of commitment to the relationship Van de Ridder et al, Med Educ 2008

47. Why feedback? Mastery of skill requires – Deliberate practice – Feedback Ericsson et al, 2007; Goleman et al, 2002

48. Brief Literature Review

49. What is the optimal ratio of reinforcing to corrective feedback? Rudy et al, Eval Health Prof 2001 :

50. What do learners want? BUT they also crave specific guidance when they make mistakes Kernan et al, Am J Med 2000; Sostok et al, Acad Med 2002

51. Features of effective feedback Tying feedback to learner’s goals Understanding the learner’s position and cultural background can help Calibrating the amount of feedback Hewson and Little, JGIM 1998

52. Relationship matters Learners often experience shame, remorse, or “impostor syndrome” even with positive feedback Prior relationships allow learners to hear constructive feedback more readily Eva et al, 2011; Chou et al, 2013

53. Goals of the session Define “feedback” in medical education Assimilate literature on feedback into an approach to giving feedback Describe a method of nonjudgmental delivery of feedback Rehearse a feedback encounter

54. Imagine a scenario Think about a learner Envision a scenario in which you would give feedback to that learner

55. Feedback Steps Set-up Gather Information / Observe ARTful Feedback – Reinforcing – Constructive – Take Homes Bienstock et al, Am J Ob Gyn 2007

56. Set-up Goal: To create a permissive environment for maximal learning – In context of learner-teacher relationship – In the spirit of dialogue rather than downloading – Signposting

57. Set-up Features – Temporally as close as possible to event – In accordance with learner’s goals: what are you hoping to achieve after this experience? – In accordance with learner’s readiness – Anticipating common issues (for procedures, may involve intervening), and promising to debrief them afterwards

58. Gather information

59. Feedback Steps Set up Gather Information / Observe ARTful Feedback – Reinforcing – Constructive – Take Homes Bienstock et al, Am J Ob Gyn 2007

60. ARTful Skills Ask: Learner’s self-assessment; recall goals Respond: Requires active listening, and sometimes empathy Teach: Your own assessment and thoughts, framed behaviorally and specifically

61. ARTful Reinforcing Feedback Ask: What do you think you did effectively? Respond, Teach The ART cycle continues: ask for reactions to your feedback

62. ARTful Constructive Feedback Ask: What do you think you’d like to do differently? Respond, Teach (remain nonjudgmental) Continue the ART cycle: ask for reactions to your feedback

63. ARTful Constructive Feedback For challenging situations, try: Asking about intention Responding with empathy or a summary Teaching your perception of how intention and impact differ

64. Take Homes “What will you take home from our conversation?” Doing this teachback allows you to – Assess impact – Measure outcomes – Ensure accountability Schillinger et al, 2003

65. Feedback Steps Set up Gather Information / Observe ARTful Feedback – Reinforcing – Constructive – Take Homes Bienstock et al, Am J Ob Gyn 2007

66. Courage is what it takes to stand up and speak. Courage is also what it takes to sit down and listen. –Winston Churchill