Feedback in Clinical Skills Session in Pre-clinical Years Dr. Steve Martin Island Medical Program

Question Can we improve acquisition of basic Clinical skills by pre- clinical years Undergraduate medical students by enhancing tutor feedback skills?

Hypothesis Improving the quality of tutor feedback to undergraduate medical students (Years 1-2) during clinical skills sessions through just-in time faculty development will improve student performance in patient history and physical examination resulting in improved patient outcome.

Hypothesis: Improved tutor feedback skills Improved quality of patient encounter and clinical outcome Enhanced acquisition and mastery of basic clinical skills by pre-clinical undergraduate medical students Faculty Development Focusing on Providing Feedback

Feedback Information describing students' performance in a given activity. Information describing students' performance in a given activity. Key step in the acquisition of clinical skills. Key step in the acquisition of clinical skills. Often omitted or handled improperly in a clinical training. Often omitted or handled improperly in a clinical training.

Literature Search Confined to: Enhancing basic clinical skills acquisition and mastery. Enhancing basic clinical skills acquisition and mastery. Feedback in Medical Education. Feedback in Medical Education. Apprenticeship /Mentorship/Modeling in Medical Education. Apprenticeship /Mentorship/Modeling in Medical Education.

Why look at this issue? Clinical supervisors often do not fail students and residents even though they have judged their performance to be unsatisfactory Dudek, Marks & Regehr, Academic Med, 2005 Clinical supervisors often do not fail students and residents even though they have judged their performance to be unsatisfactory Dudek, Marks & Regehr, Academic Med, 2005 Recent accreditation identified the need for increasing and improving feedback. Recent accreditation identified the need for increasing and improving feedback.

Why? When effective feedback is provided and focuses on directly observable skills and behaviors, important personal and educational progress can occur, Katz When effective feedback is provided and focuses on directly observable skills and behaviors, important personal and educational progress can occur, Katz

What is feedback? Information describing students' or house officers' performance in a given activity that is intended to guide their future performance in that same or in a related activity. Ende Information describing students' or house officers' performance in a given activity that is intended to guide their future performance in that same or in a related activity. Ende

Giving Feedback Observations are the currency of feedback and without them the process becomes feedback in name only. The observer must be committed to the process; moreover, he or she must have well-formed standards (goals) of clinical competence. Observations are the currency of feedback and without them the process becomes feedback in name only. The observer must be committed to the process; moreover, he or she must have well-formed standards (goals) of clinical competence.

Vanishing Feedback, Ende The teacher may be concerned that the student will be hurt by negative feedback The teacher may be concerned that the student will be hurt by negative feedback Students may ostensibly want information about their performance but only insofar as it confirms their self-concept Students may ostensibly want information about their performance but only insofar as it confirms their self-concept

Methodology 24 undergraduate second year medical students in the final stages of the clinical skills course. 24 undergraduate second year medical students in the final stages of the clinical skills course. 9 experienced physician tutors. 9 experienced physician tutors. 14 standardized patients (SP) were utilized to provide 96 encounters for 24 students. 14 standardized patients (SP) were utilized to provide 96 encounters for 24 students. FD Team FD Team

Just in-time Faculty development session FD session on Feedback. FD session on Feedback. –What was done right? –What needs improving? –What to do next time? One-way mirrored observation. One-way mirrored observation. Direct observation. Direct observation. Exit interview. Exit interview.

Bipolar Descriptors of Recommended and Nonrecommended Feedback Techniques, Hewson, 1998

IntentionTechniqueExamples of Behaviours Orientation & Climate: Prepare person for the session. Inform person ahead of time, Select appropriate time & location, Provide relaxed, respectful atmosphere, Explain/negotiate agenda Lets make an appointment to review your performance. What are your goals for this rotation? Remember the stated expectations for this procedure. Elicitation: Ask person for self-assessment.Ask what was done well and what could be improved. Ask how the person felt. Use open-ended questions. How do you think it went? What was done well? What could be improved? Diagnosis & Feedback: decide where person needs to improve & how much feedback is appropriate; give reinforcing & corrective feedback. Offer your response to observation of specific behaviours, approach or style. Give your reason in the context of well-defined shared goals. When you did/said…I was (pleased, relieved, concerned) because… Improvement plan: develop specific strategies to real situation. Invite persons suggestions. Give your suggestions. Suggest articles, consultations. Teach (discuss, demonstrate, coach) What could you do differently? This is my suggestion… Where will you get help? Lets reframe the problem. Lets talk about this. Application: Apply strategies to real situationApply planned improvements to current or future plans What will you do next time? Show me! Review: check person understands & agrees with what has been discussed & negotiated. Person reviews his/hers behaviours needing change. Specify consequences. What do you do well? What changes will you make? By when? What is you dont? Feedback Model, Hewson & Little, 1998

Data Collection Unstructured or informal discussion. Unstructured or informal discussion. Structured exit-interviews. Structured exit-interviews. Structured feedback forms. Structured feedback forms.

Outcome The common theme of all sources of feedback was that these sessions where effective in facilitating change and improvement of skill. The common theme of all sources of feedback was that these sessions where effective in facilitating change and improvement of skill.

Outcome Students felt increased confidence in patient encounters that followed each feedback encounter. Students felt increased confidence in patient encounters that followed each feedback encounter. The standardized patients sensed or perceived the increased confidence the students portrayed and thus noted improved performance. The standardized patients sensed or perceived the increased confidence the students portrayed and thus noted improved performance. Tutor identified improved skill in data collection and presentation. Tutor identified improved skill in data collection and presentation.

Physician tutors Reported: –Increased confidence in providing feedback. –Better understanding of what aspect of the clinical encounter to focus their attention on to best serve the students needs and identify significant areas of need for improvement. –Improved comfort with the ability to phrase the feedback in a constructive manner.

Conclusion/Reflections: Just-in time faculty development focused on providing feedback in clinical encounters was effective in improving the skill level of the student and tutor.

Dissemination Opportunities Results of this research will be used to change the way the clinical skills curriculum is delivered to undergraduate medical students. This will allow the trained tutors to utilize the skills gained during the FD session during the system-based clinical skills sessions.

PEARLS Engage the learner in understanding the relevance and need to receive feedback. Engage the learner in understanding the relevance and need to receive feedback. Engage the teacher in the relevance and need to provide feedback Engage the teacher in the relevance and need to provide feedback

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