Lesson Plan - Session 4 - Giving Feedback
Learning objectives
By the end of this module, participants will be able to:
• Administer constructive feedback to learners
• Explain the INSIGHT approach to feedback
• Employ effective feedback techniques
Lesson Plan
1) Welcome
a) Orientation to the Giving Feedback module
i) Faculty introduce the module and explain the logistics of the session.
b) Orientation brainstorming exercise
i) Faculty lead the group in a brainstorming activity based on the following prompt
questions.
(1) How can we best give constructive criticism?
(2) How can resident teachers deal with “difficult” learners?
2) Practice giving feedback
a) Break residents into pairs
b) First resident does feedback case
i) Resident observer/faculty fills out checklist
ii) Detailed feedback using checklist
c) Second resident does feedback case
i) Resident observer/faculty fills out checklist
ii) Detailed feedback using checklist.
3) Introduction to Feedback: Slides
a) Learners in Difficulty
i) We are all in difficulty sometimes.
ii) First, diagnose your learner:
(1) Temporary stressors
(2) Knowledge or skill deficits
(3) Attitudinal issues
(4) Learning disabilities
(5) Drug or alcohol problems
b) Why is feedback important?
i) Feedback is the lifeblood of learning.
ii) There is a human tendency toward inaccurate self-assessment.
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iii) Reflective capacity is an essential characteristic for professional competence (Mann,
Gordon, & MacLeod, 2009) then feedback from teachers and other learners is a
critical step in the process,
c) It works!
i) If done correctly, feedback:
(1) Improves learning outcomes
(2) Deepens learning
(3) Encourages pursuit of understanding application
d) Feedback models
i) There are a few different models for effective feedback. We are only going to
examine three:
(1) Sandwich
(2) One Minute Preceptor
(3) Insight approach
e) Sandwich
i) Who is familiar with the sandwich method?
(1) i.e., focus on the good news, sandwich in the bad news, and then end with more
good news.
ii) Challenges:
(1) People don’t hear the first good news because they know the bad news is coming.
(2) Most high performing people want to know what they can do to improve. They
don’t necessarily want the blow softened.
f) One minute Preceptor
i) Also known as the “Five Microskills of Clinical Teaching” the One Minute Preceptor
is an evidence based practice that if done correctly saves time when giving feedback
in a clinical environment.
ii) This is the method we are recommending.
g) Why?
i) Why are we recommending this method of clinical teaching?
(1) Teaches clinical reasoning solving – It’s our nature as teachers to want to provide
answers. Students learn more, however, when we ask them to seek their own
answers. This process encourages the learner to think for themselves.
(2) Shows gaps in reasoning and knowledge – It helps clearly show where there may
be gaps in student understanding. This means you can focus your teaching
specifically to areas where the need exists. You can avoid spending time
explaining things the learner already understands and missing the opportunity to
diagnose any problem areas.
(3) Identifies teachable moments – Once you have seen the gaps in understanding,
you can seize on those teachable moments. You will see the opportunity to drive
home a specific point.
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(4) Creates a clear, consistent method – Since learners are learning at different sites
and with different attending physicians, this method provides a point of
consistency in the way they are taught and the way they are evaluated. So,
regardless of which site a student ends up at, they are gaining and equivalent
learning experience. (Not the same, mind you, but equivalent.)
ii) The One Minute Preceptor has five steps. We will cover each one.
h) Step 1 – Get a commitment
i) Commit to a differential diagnosis or assessment of problem.
ii) Begin by asking the learner to commit to a decision. This allows the student to
process the information and leads to deeper learning.
iii) It asks the learner to commit to a diagnosis or treatment option, rather than just
agreeing with the preceptor’s plan.
iv) Avoid prompting the learner or suggesting any actions at this point.
i) Ask in a Non-threatening Way
i) Ask:
(1) What do you think is going on here?
(2) What do you want to do next?
(3) What kind of investigations are indicated?
(4) What would be your treatment plan?
j) Step 2 – Probe for Supporting Evidence
i) Next, have the student explain their reasoning.
ii) Explore the learner’s thought process. This gives you the opportunity to assess the
learner’s clinical reasoning and to determine if there are any gaps in reasoning or
misconceptions.
iii) The purpose of this step is to identify any learning gaps so you can determine what
they don’t know and what you can teach them.
k) Asking probing questions
i) Ask probing questions without judgment:
(1) What lead you to that diagnosis?
(2) Why did you choose that drug?
(3) What factors did you consider in making that decision?
(4) What made you choose that particular treatment?
(5) Were there other options you considered and discarded?
(6) What other alternatives did you consider?
(7) How did you rule out other options?
(8) If this patient was pregnant, would it alter your management?
ii) This step identifies gaps in reasoning.
iii) It needs to be a positive learning climate. It won’t work if the learner feels like they
are being cross-examined.
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l) Step 3 – Teach General Rules
i) After the student has had an opportunity to develop an assessment, backed up by
verbalized reasoning, the preceptor may take a moment to do some targeted teaching
about the specifics of the patient’s problem.
ii) This teaching can be brief and focused on one specific teaching point derived from
the case. (Association of Professors of Gynecology and Obstetrics)
iii) Learning a way to approach the problem is more effective than learning isolated facts.
The student learns to organize their knowledge and generalize it for other situations.
Base the general principle you are teaching on any learning gaps you identified in the
previous step.
iv) This can be about symptoms, differential diagnosis, treatment, and more.
v) Choose a single, relevant teaching point.
vi) Check the learner for understanding of the principle you are teaching.
vii) Avoid anecdotes or personal preferences.
viii) You might skip this step entirely if it is clear that the learner knows the principles
well.
m) Step 4 – Reinforce what was done right
i) Reinforcing good behaviors is an essential part of learning and ensures that students
continue using them.
ii) Focus on behaviors that were beneficial to the patient, colleague or clinic.
iii) The best reinforcement is specific and focused.
(1) You did a good job of _______________ because _________________.
iv) Be specific and focus on patient interaction, oral presentation, reasoning processes,
etc.
n) Reward competencies
i) Specifically, you did a good job of . . .
ii) Here’s why that is important. . .
iii) Avoid general praise like, “Great job!”
o) Step 5 – Correct Mistakes
i) This step helps ensure that correct knowledge has been gained and creates a
foundation for improvement.
ii) While no one wants to be overly critical, avoiding confrontation and ignoring errors
guarantees they will be repeated.
iii) Focus on future behavior rather than dwelling on the error. Teach the student how to
avoid making the same mistake next time. Begin with the student self-assessment as a
launching off point.
iv) Correct any mistakes the student made. Be specific.
v) Identify any knowledge or reasoning gaps. Focus on how the student might improve
their practice the next time.
vi) Point out areas for the student to work on in self-directed learning.
vii) Provide suggestions on resources, if appropriate.
p) Be specific
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i) Specifically, you did a good job of . . .
ii) Here’s why that is important. . .
iii) Avoid general praise like, “Great job!”
iv) Comments like “Your patient communication needs to be better” are not helpful since
that could refer to the clarity of the student’s comments, their friendliness, their
professional demeanor, etc. To respond to fuzzy performance, you might try: “How
else could you have explained this to the patient?”
q) The INSIGHT Approach
i) Inquiry
ii) Needs
iii) Specific
iv) Interchange
v) Goals
vi) Help
vii) Timing
r) Inquiry
(1) How does the learner think things are going?
(2) Listen to the learner’s needs in detail.
(3) Listening attentively and thoroughly before commenting may be all you need to
do, especially for minor/temporary problems.
s) Needs.
(a) What does the learner feel s/he needs during this rotation?
(b) Ask the learner to define own learning needs.
(c) Learners accept feedback better when they feel the teacher has first
understood their perspectives.
t) Specific
(a) Give your constructive feedback as specifically as you can.
(i) Start with specific positive feedback.
1. The more learner-centered the feedback, the better it will go.
(b) Verify the learner’s understanding of the feedback you’ve given.
u) Interchange
(1) How can you best balance the learner’s needs with the team’s needs?
(2) You may need to think creatively to find a mutually satisfying solution.
v) Goals
i) State any new goals you’ve just reached, or review existing goals.
ii) Verify that you both understand and agree on these goals.
w) Help
i) Do any serious problems merit a learning consultation?
(1) Chief resident
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(2) Attending physician
(3) Learning specialist
(4) Employee assistance program
(5) Others
x) Timing
i) Any final questions or comments?
ii) When would you and the learner like to meet again to go over how things are going?
y) Tips
i) Here are a few additional tips on giving effective feedback.
z) Timely
i) Immediate – Feedback has a short shelf life because you can’t expect the student to
remember every detail of their performance.
ii) Try to give the feedback while the behavior is still fresh in the student’s mind.
aa) Forward Focus
i) Focus forward – Give small actionable items for next time. Ideally only one or two.
That will end the discussion on a positive note and give the student something to
focus on.
ii) You don’t want a laundry list.
iii) Keep it brief. 2-3 suggestions is enough for the student to work on in the short term.
bb) Based on trust
i) We tend to reject feedback if we don’t trust the messenger or feel like they have some
kind of agenda of their own.
ii) You must build credibility and rapport. The student must understand that the
feedback is for their own good.
cc) Balanced
i) Balances negative and positive.
ii) If it’s too positive - students will gloss over mistakes and think they did everything
right.
iii) If it’s too negative – students will become discouraged and think they did nothing
right.
dd) Explain impact
i) Point out the direct results of the behavior. Using statements like “I noticed” or “It
made me feel” are difficult to argue with. You avoid devolving into a debate about
why I did it the way I did it. Example: “I noticed the patient was a little agitated.” Or
“It made me feel like you wanted to get out as quickly as possible.”
ii) Focus on how the behavior effected the patient or the practice.
ee) Judgmental vs. Descriptive
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i) Avoid any language that makes a judgment. Use language that describes behavior,
then explain why that may have been a good thing or a problem.
ff) Deduction vs. Observation
i) Focus on observable behavior and avoid judgment calls.
ii) Comments like, “You don’t seem comfortable with older patients” is a deduction.
You are deducing this from what you have observed. But you can’t know what
caused the behavior you observed. You are just guessing.
iii) Try: “I noticed that when you interviewed that older patient, you failed to make eye
contact or use his name.”
gg) Questions?
(1) Do you have any questions on giving feedback?
4) Closing
a) Review of key concepts
b) Large group summary of what was learned
c) Introduction to the next module
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