Giving Effective Feedback to Interns & Residents

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This post was by request from an experienced clinician who is seeking more tips to improve giving feedback to advanced clinicians-in-training.  I don’t really have all the answers, but here are some ideas I hope will help.

First, effective feedback has three fundamental requirements: it has to be timely, it has to be specific, and it has to focus on behaviors.

1) Timely.  Instead of waiting for the end of a rotation, or the bi-annual resident evaluation, give feedback the same day you observe something.  Feedback can be positive, like “I think you did a good job handling that case” or it can be developmental, “I’d like you to be able to calculate the bicarbonate dose on your own next time.”  The sooner it can happen after an experience, the better.

2) Specific.  You want feedback that is directed at specific things the student did.  What they did, how they did it, or why they did it.  General statements tend to be internalized as feedback about the PERSON, rather than their behavior.  That is, general feedback like, “I think you did well” tends to be internalized as “I am a good person”.  Conversely, feedback such as, “I don’t think you handled that well” tends to be internalized as “I am a bad person”.  Specific feedback such as, “You were well prepared for that catheter placement” and “Make sure you have your T-port ready for your catheter next time” allows the recipient to understand exactly what they did well or what they need to improve on.

3) Behavior-focused.  Feedback should focus on behaviors, not global assessments of a person. You want to focus feedback on the WHAT, not the WHO.  You want feedback to focus on WHAT they did.  “I think you did a good job assigning roles to everyone during that emergency case” is an example of positive, specific feedback.  It focuses on WHAT they did.  “For future cases, I’d like you to think about how you can get the case into the OR more quickly” is an example of developmental, specific feedback.  It focuses on WHAT you want them to do.

I have heard rules-of-thumb that you should give X positive pieces of feedback for every Y piece of developmental feedback.  I think that’s generally a good approach: if you give out positive feedback, people will tend to be more receptive to developmental feedback.  I am a big fan of the feedback sandwich, where you give the person one thing they did well, one thing they can improve on, and finish with one thing they improved from the last time.  For example, “I think you did a good job remaining calm during that case.  The next time you have a case like this, try to think ahead of what you may need so it’s already there for you.  Your catheter placement speed has become a lot better in the past few weeks, which helped get the case to the OR in time.”

I am also a huge believer in guided reflection for providing feedback.  I will almost always start a discussion when I want to give feedback with, “How do you think that went?”  This allows the student to reflect on the event, and many times they will identify the very things you were going to give them feedback on.  This also supports their autonomy– they get to participate in the learning experience.  I find that, when students are allowed to reflect on an event and give their perspective, they are eager for my feedback.  This makes it much easier to provide feedback- the student isn’t in a defensive state of mind, but a receptive one.

I can think of three contexts for giving feedback to interns and residents: during a procedure, immediately after a case, and at the end of a week or block.

During a Procedure

  • I like to ask the student, “Can I give you some suggestions?” or “Do you mind if I give you some ideas on doing this?”  Asking permission involves the student in the decision to receive feedback, makes them more receptive, and frames what you’re about to tell them.  This is particularly valuable when they are in the middle of learning a challenging skill (arterial catheter placement, endoscopy, arthroscopy, etc.).
  • Summarize what they are doing and then tell them how you do it and point out how this differs, if necessary.  Don’t say “this is the right way to do it” but rather “this is how I like to do this.”  That gives them permission to accept your feedback or try it another way.  This is particularly important for residents who hear different things from their different mentors.

Immediately After a Case

  • Initiate a dialogue about the event by asking the student to reflect on it.  “How do you feel that case went?”  “What went well for you with that case?”  “What questions do you have about that case?”  “What do you want to do differently in the future” are my favorite questions.
  • Allow the student to reflect.  If they identify one of the areas for improvement that you wanted to bring up, great.  Hang on to that for when you give your feedback.  I find students often don’t give themselves enough praise- they only see the negative things they did.  So part of your role is to make sure to support their competence while also developing it.
  • Provide your positive, supportive feedback.  “I think you did this specific thing well.”  “I think you handled yourself well (managed stress, etc.).”  “I think that case went as well as it could have given its illness.”  Again, don’t make general statements here, “I think you did well!”  “I think you did a good job!”
  • Provide your specific, developmental feedback.  If they mentioned something during reflection, bring that up.  “Like you said, I agree you could have been more prepared.  Now you know what to do going forward!”  “Maybe next time you can work on being more prepared.”
  • If appropriate, provide a positive note to close on.  “It’s sad that the case didn’t survive, but I think we did all the right things for it.”  “I think your speed in managing cases has improved, and that definitely helped this case.”  “That was a difficult talk with that client, and I’m glad you were able to conclude it without getting angry at them.”
  • Thank them for their time and end with a positive departure.  Although you are the teacher and they are the student, they are opening themselves up to you to help them improve, which creates vulnerability.  Thank them for their time and that vulnerability (not necessarily explicitly).  “Great, thanks for thinking about the case and discussing it with me.  I will see you bright and early tomorrow morning!”

At the End of a Week or Block

  • Ask the student how the week went.  “How did the week go for you?”  “What went particularly well?”  “What were your challenges?”  If you have noticed specific areas for improvement- such as teaching students- you can ask about that directly.  “How did you feel your student teaching went this week?”
  • Provide your positive, supportive feedback.  “I think you did this specific thing well.”  “I think you handled yourself well (managed stress, etc.).”  “I think that case went as well as it could have given its illness.”  Again, don’t make general statements here, “I think you did well!”  “I think you did a good job!”
  • Provide your specific, developmental feedback.  If they mentioned something during reflection, bring that up.  “Like you said, I agree you could ask the students more questions about the cases”  “In the future I’d like you to think about asking the students more questions.”
  • If appropriate, provide a positive note to close on.  “We had a difficult week, but I appreciate your focus and dedication to the service.”  “I think you have improved a lot this week and I look forward to seeing what you do with it next week.”  “I know you had some difficult clients this week, so I am glad you were able to stay positive and learn from those encounters.”
  • Thank them for their time and end with a positive departure.  Although you are the teacher and they are the student, they are opening themselves up to you to help them improve, which creates vulnerability.  Thank them for their time and that vulnerability (not necessarily explicitly).  “Great, thanks for the time to talk about the week and your work this week.  I will see you bright and early Monday morning!”

What do you think?  Are there any feedback challenges you have had which are not encompassed in this framework?

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