10-6 YES!: Improving Verbal Feedback
October 06, 2023ID10829
To CiteDCA Citation Guide
- 00:00And push the button.
- 00:11Thanks, Ed. So I think we'll get started.
- 00:16Welcome to the Yale Medical Education Series.
- 00:19It's yes, for short.
- 00:20We took a little bit of time
- 00:22trying to think of a great acronym.
- 00:24So leaving the M Out and Yale
- 00:27Medical Education series, yes,
- 00:29it's sponsored by the Center for
- 00:32Medical Education, of which I'm a part.
- 00:35And the series is directed by
- 00:37Doctors Dana Dunn and Andres Martin.
- 00:40Doctor Martin will also be you'll be
- 00:41hearing from him a little bit because he'll
- 00:44be moderating the discussion in a bit.
- 00:45And both are faculty associates
- 00:48at the center today.
- 00:49We have two skillfully
- 00:51wonderful educators with us.
- 00:53Doctor Susan Kashoff is a longtime partner
- 00:56and a colleague in Yale Medical education.
- 00:59She's an adult primary care physician.
- 01:02She's associate professor of medicine and,
- 01:04importantly, a student advisor through
- 01:07the Office of Student Affairs.
- 01:09Based at the VA Primary Care Clinic.
- 01:12Her educational contributions are many.
- 01:14They've included teaching medical
- 01:16students on topics like problem focus,
- 01:19patient exams, issues of professionalism,
- 01:23clinician responses to intimate
- 01:25partner violence, and many,
- 01:28many more.
- 01:29Joining her is doctor Uma Patak,
- 01:32who's a pediatrician,
- 01:34associate professor of Pediatrics,
- 01:36and director of the pediatric component
- 01:38of the Women's and Children's
- 01:41Health Integrated Clerkship,
- 01:42A mouthful.
- 01:44She's also a director of the Pediatric
- 01:48Gastroenterology,
- 01:48Hepatology and Nutrition Fellowship,
- 01:50an alumni of the Center's Medical
- 01:53Education Pathway Masters Program.
- 01:56Her thesis in that program was
- 01:58on today's topic,
- 02:00improving feedback and medical education,
- 02:02so you'll be hearing some rich things from
- 02:06her that stem from her thesis and beyond.
- 02:09Both Uma and Susan are alumni
- 02:12of Yale GME Training Program.
- 02:14Zuma did her fellowship and Susan her
- 02:17residency at Yale New Haven Hospital.
- 02:19So they've been around a while.
- 02:21And both were clinical assessment
- 02:23coaches in the pilot program to
- 02:26what's now called the Longitudinal
- 02:28Coaching Program for Medical Students,
- 02:30which is currently in its inaugural year.
- 02:33So at some point we can talk
- 02:35about all these things.
- 02:36If not today,
- 02:37they're all important things
- 02:39that are happening at Yale.
- 02:41So both Susan and Uma have lots
- 02:43to teach us about feedback.
- 02:46So it is with great gratitude that
- 02:48I handed over to the two of them.
- 02:53Great. Well, welcome everyone.
- 02:55I'm going to share my screen.
- 02:58Thank you very much for spending
- 03:00your lunch hour with us talking
- 03:03about this important topic.
- 03:05And there we go away from start.
- 03:08OK. So today we're going to be
- 03:11talking about verbal feedback.
- 03:13Specifically,
- 03:14there is a session coming up
- 03:16on written feedback in January,
- 03:18and we're going to build on the
- 03:21previous sessions on Learning Climate.
- 03:24So I think you've seen this,
- 03:25but to record your participation,
- 03:27you can text your attendance to that number.
- 03:31And we'd like to acknowledge the A/C
- 03:34Zone with Faculty Development Toolkit,
- 03:36which is a fantastic resource.
- 03:38I'd encourage you to take a look
- 03:39at and also Walter Kernan for a
- 03:42video that we're going to use
- 03:43to practice the skills together.
- 03:47So education without feedback.
- 03:50We've created a safe,
- 03:51nonjudgmental environment that will leave
- 03:53your child ill prepared for real life,
- 03:55and I would argue that it is
- 03:58the same for our trainees.
- 04:00We give education without feedback,
- 04:03so our goals today are to start by
- 04:06discussing what makes for useful feedback,
- 04:09describe some barriers to feedback,
- 04:12and learn and practice a model
- 04:14of feedback together.
- 04:18So what defines constructive feedback?
- 04:21There are a few articles from ND,
- 04:24who's the father of feedback in medicine,
- 04:26which articulate the principles
- 04:28of effective feedback.
- 04:30And interestingly,
- 04:30when looking at the feedback literature,
- 04:33a lot of it is in teaching,
- 04:35in business, and in coaching.
- 04:37But it's really the same basic
- 04:40principles that come up again and again.
- 04:42So perhaps most importantly,
- 04:44constructive feedback needs to be well
- 04:48intended and based on shared goals.
- 04:51So this really builds off of that
- 04:53positive learning climate that
- 04:54we've talked about before and
- 04:56that learning climate needs to be
- 04:58established early and reinforced
- 05:00throughout the rotation month, year,
- 05:03however long you have with that learner.
- 05:05So that that learner really believes
- 05:07that the feedback is for their benefit
- 05:10and is based on the fact that you care
- 05:12about their professional development.
- 05:15So effective feedback is
- 05:17behavior or performance based,
- 05:20is directly observed based on firsthand
- 05:23information as opposed to hearsay,
- 05:25and is specific enough so that the IT can
- 05:30be useful but also needs to be manageable.
- 05:32So giving someone a lot of feedback
- 05:35points might make it overwhelming.
- 05:37It also needs to be within the
- 05:39realm of what can be changed and
- 05:42ideally it should be timely or
- 05:44close to the time of observation.
- 05:47So there are a lot of barriers to feedback.
- 05:49We'll talk about some of them and but
- 05:51really in the feedback equation there
- 05:53are three factors that are important,
- 05:54the teacher,
- 05:55the learner and their environment.
- 05:57So we're going to talk about each of those
- 06:00factors and what barriers there are and
- 06:02what opportunities they can represent.
- 06:04So what gets in the way of feedback
- 06:06at the level of the teacher?
- 06:08There are competing demands,
- 06:10so when I'm listening to my medical
- 06:13student presenting the patient on rounds,
- 06:17I'm also listening to what is happening
- 06:20with the patient and trying to do the
- 06:23clinical care around that patient.
- 06:25There are time and space constraints,
- 06:27so maybe I'm walking into the patient room.
- 06:30Maybe that student or night resident is
- 06:34leaving because duty hours are being met.
- 06:38There's variable amounts of
- 06:39training so we can all have some
- 06:41discomfort around giving feedback.
- 06:43Hopefully we can address that
- 06:45today and it's really hard to do.
- 06:48It's uncomfortable to give,
- 06:50especially what can be
- 06:52seen as negative feedback,
- 06:53and there can be an emotional
- 06:56reaction in both parties.
- 06:57And finally,
- 07:00there can be a fear of retaliation,
- 07:01which is sometimes well founded.
- 07:04Negative about negative feedback
- 07:05can have adverse consequences to
- 07:07the faculty member that's giving it
- 07:08and that could just be extra work
- 07:10and trying to work through through
- 07:12that with the person or stress.
- 07:14I mean I have been up at night thinking
- 07:17about the the challenging feedback
- 07:19I'm going to give to someone or even
- 07:23retaliation in the form of evaluations
- 07:26that are negative of of us as the
- 07:30educator at the level of the learner.
- 07:31There are also barriers
- 07:33to getting that feedback,
- 07:35to accepting that feedback and
- 07:38to incorporating that feedback.
- 07:40So first of all,
- 07:41we're really bad at assessing ourselves.
- 07:4493% of American drivers
- 07:46think they're above average.
- 07:47I am among the 7% who knows I am
- 07:51below average as a driver also.
- 07:53It's interesting and I'm
- 07:54sure you've seen this,
- 07:55that sometimes the lower performing
- 07:58residents don't readily identify
- 07:59their weaknesses and actually
- 08:01can overestimate their abilities,
- 08:03while the higher performing
- 08:05residents can underestimate their
- 08:07skills in core competency areas.
- 08:10And interestingly,
- 08:11we all think that we're better at
- 08:14self-assessment than we are and better
- 08:16than others at assessing our needs.
- 08:18So Kevin Ava,
- 08:20who is a leader in this in this area,
- 08:23calls that the they not we phenomenon.
- 08:25And finally,
- 08:26even if we're fully aware of our weaknesses,
- 08:28we're often afraid to reveal
- 08:30those weaknesses to the person
- 08:31who's going to be grading us.
- 08:33So that's the coach versus judge phenomenon.
- 08:35So when the person that's teaching
- 08:39someone is also the person that's
- 08:41assessing them and determining
- 08:43their future opportunities,
- 08:44that can be stressful as opposed
- 08:46to a coach who's really there just
- 08:49to help improve clinical skills.
- 08:51The judge is responsible for
- 08:53assessing that trainee's performance.
- 08:55And as clinical supervisors,
- 08:56we have that dual role which can
- 08:59make the the trainee less likely
- 09:01to reveal their weaknesses even
- 09:03if they are aware of them.
- 09:05And finally,
- 09:06there are different types of
- 09:09learner goal orientation,
- 09:11so there can be performance oriented.
- 09:13So like the goal is to look smart
- 09:15or learning oriented where the goal
- 09:17is to improve and our environment
- 09:19which is really achievement based
- 09:21and high stakes and competitive at
- 09:23times may induce more of a performance
- 09:26goal orientation which can lead to
- 09:28avoidance of that essential feedback.
- 09:30So really trying to foster that
- 09:33growth or learning mindset can
- 09:34increase the receptivity to feedback
- 09:37and feedback seeking behavior and
- 09:39support the development of mastery.
- 09:43There are also systems barriers to feedback
- 09:47in addition to the teacher and the
- 09:49learner in terms of the learning culture.
- 09:50So in addition to the lack of time that we
- 09:53talked about and competing priorities and
- 09:55variable amount of training and discomfort.
- 09:57There is now even less continuity and
- 10:00and fewer opportunities to observe and
- 10:03assess our learners with the tending
- 10:05blocks as short as one or two weeks and
- 10:08constant turnover of trainees and and and
- 10:12educators often mismatched with each other.
- 10:16So there's also a hidden
- 10:18curriculum in medicine.
- 10:19A pressure to perform a fake
- 10:20it till you make it mentality.
- 10:22That and the need to not appear incompetent.
- 10:24Again because of our achievement based
- 10:27high stakes competitive environment
- 10:29that can make us hesitant to seek
- 10:31feedback that can be negative
- 10:35even when we're giving feedback.
- 10:37Often some of the problem is that it might
- 10:39be mismatched with what our learning is.
- 10:42Learner is asking for is there's a great
- 10:44book called Thanks for the Feedback and
- 10:47they categorize the types of feedback,
- 10:51all of which are essential into 3 categories.
- 10:53So appreciation which is recognition,
- 10:56motivation and thanks.
- 10:57It helps you know that your efforts are
- 10:59noticed and makes you feel worth a lot.
- 11:02Coaching which is more help.
- 11:04It helped aimed at helping you improve,
- 11:06learn, grow and change either to meet new
- 11:09challenges or to correct an existing problem.
- 11:11And then evaluation,
- 11:12which is really assessment.
- 11:14It tells you where you stand in relation
- 11:16to expectations and to other people,
- 11:17and it helps align expectations between
- 11:20people and clarify consequences.
- 11:22So if we're giving someone feedback,
- 11:25that is appreciation.
- 11:26But what they're really wondering is,
- 11:28am I on par with my peers?
- 11:30Am I on track for promotion and graduation?
- 11:32That can be unsatisfying to that person.
- 11:36I'm sure you've all been in the situation
- 11:38where you're giving someone feedback
- 11:40and they, you know, they're like,
- 11:42waiting for the shoe to drop.
- 11:44They're waiting for that feedback sandwich.
- 11:45You say something nice,
- 11:46you're going to say something that's,
- 11:48you know,
- 11:49negative and then say something nice again.
- 11:51And I've actually had people like,
- 11:53where's the middle of the sandwich?
- 11:54Like,
- 11:54where are you going to tell me the things?
- 11:56Is there something you're not telling me
- 11:59or you are giving them again appreciation,
- 12:03but they're really looking for coaching.
- 12:05So what it is that they can do better.
- 12:09So the implications of that lack
- 12:12of effective feedback are many.
- 12:14So there can be missed
- 12:15learning opportunities,
- 12:16there can be learner and security
- 12:18and feeling like they're just being
- 12:20praised or passed along without really
- 12:22knowing what they can be better at.
- 12:24We can have inaccurate perception
- 12:25of performance by the learner.
- 12:27So they think they're doing great
- 12:29or they think they're doing poorly
- 12:31without really knowing what what their,
- 12:35what their educators,
- 12:36what their teachers think.
- 12:38And there can be a performance
- 12:40plateau and we're no longer
- 12:41coaching people for improvement.
- 12:42And finally there can be disappointment
- 12:44surprised with final evaluations.
- 12:46So as an advisor,
- 12:47I see this often where people have
- 12:49not been told the things that that
- 12:50they could be doing better and then
- 12:52they get their final evaluation
- 12:54and that's surprising to them and
- 12:56they haven't had the opportunity to
- 12:58to really talk about those things.
- 13:01So I'm going to pass this along
- 13:04to Doctor Fattock to talk about
- 13:05a way of doing this better.
- 13:09Thanks Susan, and thank you,
- 13:10John for that kind introduction
- 13:12and the organizers for the
- 13:14opportunity to speak today.
- 13:16Really excited to talk on an
- 13:18important topic of feedback.
- 13:20And Susan just gave you the background
- 13:23in terms of the importance of
- 13:26feedback conversations as well as
- 13:28what the barriers we all encounter
- 13:31in our daytoday lives in having
- 13:33these type of conversations.
- 13:35So now we'll switch gears a little bit
- 13:37and talk about in the next few slides,
- 13:40an interactive model of giving back that
- 13:43all of you will utilize in practice
- 13:46when you go into breakout rooms and
- 13:49the end of that section of our talk,
- 13:52because really a large part of feedback
- 13:54is practicing how to get better at it.
- 13:58Before we start feedback
- 14:00conversations though,
- 14:01it's really important to set the stage
- 14:04for those feedback conversations and
- 14:06it's extremely important to normalize
- 14:09feedback and we cannot highlight
- 14:11the importance of spending time in
- 14:14this piece of feedback before you
- 14:17actually launch into that conversation.
- 14:20So as Susan mentioned,
- 14:22the learning climate is extremely important.
- 14:24So when we're preparing to
- 14:26give feedback to our trainees,
- 14:28it's important to promote relationships,
- 14:31important to really spend time building
- 14:34and fostering a warm learning climate.
- 14:37Establishing goals as Susan mentioned,
- 14:40not necessarily just performance
- 14:43focused goals,
- 14:44but perhaps mastery goals is
- 14:47also important and having them
- 14:50be small achievable goals is can
- 14:53sometimes be more impactful.
- 14:55It's also helpful to think about
- 14:57the setting when where this
- 14:59conversation is going to happen.
- 15:01We're often in busy clinical settings and
- 15:04it's difficult for us to really find space,
- 15:07but but spending some time and
- 15:09thinking about that might be helpful.
- 15:12And the the last point is I think
- 15:13we've all been there, right?
- 15:15We've,
- 15:15we've given feedback to our trainees and
- 15:18we've felt like we've given feedback.
- 15:21But a lot of times when our trainees
- 15:24complete evaluations or are asked about it,
- 15:26they feel like they've not
- 15:28received feedback from us.
- 15:30So it's really important to signpost it.
- 15:33So before you start that feedback dialogue,
- 15:36it's helpful to say, OK,
- 15:38now I'm going to give you feedback,
- 15:40so don't hesitate to use
- 15:42that eight letter F word.
- 15:48So why are goals important?
- 15:50Because we all need to have a
- 15:53shared mental model of what our
- 15:55conversation is going to be about.
- 15:58So I I love this, this cartoon
- 16:00that I will let all of you read.
- 16:03But it's it's really important that we
- 16:06set goals such that the trainee feels
- 16:08like they're being heard as well as
- 16:11we're giving them feedback on exactly
- 16:13what they're looking for feedback on.
- 16:16So setting goals is a shared
- 16:19process where we discuss and come
- 16:22up with some set goals and you can
- 16:25ask about goals utilizing Susan.
- 16:28If you could please press the next button.
- 16:32Questions such as what do you
- 16:34hope to get out of this rotation.
- 16:36Sometimes you might need to be a
- 16:38little bit more directive and say
- 16:40my goals for your week on X are and
- 16:43then we could work together on those
- 16:45or what are you working on that
- 16:47you want to continue to work on.
- 16:49So these are some of the ways
- 16:51you can help to set goals.
- 16:55So next we'll talk about
- 16:57an interactive model,
- 16:59a learner focused model of giving feedback,
- 17:02which is called the Adapt model.
- 17:03And this is just one of many
- 17:06models of giving feedback.
- 17:08What we like the specific model
- 17:13because of that initial asks ask
- 17:17which helps to helps the feedback
- 17:20ever understand the insight of the
- 17:23person who's receiving the feedback.
- 17:24So the adapt model stands for
- 17:27the first A is ask, discuss,
- 17:30ask and plan together.
- 17:33So the first ask
- 17:38is, is where you assess for
- 17:43insight for learner insight.
- 17:46And I think Susan talked about this and
- 17:49that as physicians there's abundance
- 17:51of literature to suggest that we're
- 17:54not very accurate at self-assessment
- 17:56and same with our learners.
- 17:58So it's important to ask them what they
- 18:01feel their performance was like or
- 18:04how they felt they did and it really
- 18:07can help you tailor your feedback
- 18:10conversation to that learner perception.
- 18:12So examples of asking for that initial
- 18:15ask are how do you think that when
- 18:18or how do you think things are going?
- 18:21You can hone in directly on what's
- 18:23going well.
- 18:23So you could say what's going well,
- 18:24what went well,
- 18:25or you could ask them what may
- 18:28not have gone so well.
- 18:30Or you could be very specific
- 18:31and just directly ask them what
- 18:33do you want feedback on.
- 18:34So these are some ways of making
- 18:37sure you ask about that first.
- 18:41Ask Once you have done that,
- 18:43the next step for the next D in the ADAPT
- 18:47model is to discuss your observations.
- 18:49And I just want to again
- 18:51highlight the word observations.
- 18:52So you're being a behavioral
- 18:55diagnostician and you're describing
- 18:58what you have observed and your
- 19:00observation should include some
- 19:02positive and reinforcing comments,
- 19:04should include some corrective comments.
- 19:07They should be very specific
- 19:09though to that shared goal that you
- 19:12came up with that at the outset.
- 19:14A lot of times we have a lot to
- 19:17say and our trainees might get
- 19:19overwhelmed with all of the information
- 19:21that we provide them.
- 19:22So it's important that we monitor and
- 19:25control our our discussions such that
- 19:29we've prioritized our discussions
- 19:31to maybe two or three observations
- 19:33about our trainees so that they
- 19:35can digest it and our feedback
- 19:37is a little bit more impactful.
- 19:41Our tone matters.
- 19:44The content matters, and it's important
- 19:47to be descriptive and not interpretive.
- 19:49So, for example, it's not okay to
- 19:52say that your history was inadequate,
- 19:54but it is okay to say that,
- 19:57you know, as I was observing you,
- 19:58I noticed that you omitted a
- 20:00few key parts of the history
- 20:02and then described those parts.
- 20:04To your learner.
- 20:05So here we're talking about their
- 20:07behavior or their performance,
- 20:09but we're not talking about them so
- 20:12that it's not a judgmental conversation.
- 20:17The next ask clarifies what the learner
- 20:21took away from that conversation
- 20:23that you had or the feedback
- 20:25dialogue that you had with them.
- 20:27And here you're asking them for
- 20:30opportunities for change and for development.
- 20:34And here you can get a sense of
- 20:37understanding of how receptive was your
- 20:39learner to the feedback you just gave them.
- 20:42So you could elicit this ask by
- 20:44questions such as what are your thoughts
- 20:46about that or does that make sense,
- 20:48anything that stuck you as some
- 20:51struck as something to work on?
- 20:56And then the last part
- 20:58of our adapt model is the plan together.
- 21:03I will say that oftentimes this is
- 21:04one of the forgotten pieces of the
- 21:07feedback conversation where all of us
- 21:09are good at at having that conversation,
- 21:11but then we sometimes might forget
- 21:14actual tangible steps to come
- 21:17up with for improvement.
- 21:18So here the plan together is such
- 21:21that you're trying to get the
- 21:24learner from point A to point B.
- 21:26So you're you're coming up with certain
- 21:28ways for them to improve strategies that
- 21:32they can work on and the action plan can.
- 21:35You can ask them questions such as
- 21:37how might you work on X or who or
- 21:40what might help you with this change,
- 21:42what might get in the way.
- 21:43Because oftentimes there might be
- 21:45barriers to bringing about change
- 21:47and and trying to work on those
- 21:50might be most impactful.
- 21:52Or you can again be a little bit
- 21:53more directive in that learner
- 21:54who needs that extra help,
- 21:56where coaching might not be the
- 21:58greatest but rather advising might
- 22:00be more helpful where you can say,
- 22:01OK, here are my suggestions to
- 22:04you for your action plan and let's
- 22:07see you work on these.
- 22:10So that is the ADAPT model.
- 22:13And
- 22:16Susan, if you could just go,
- 22:19essentially this is a handout
- 22:21of the ADAPT model that we will
- 22:25plug in the chat really quickly.
- 22:28We are going to go into breakout
- 22:31rooms to practice using ADAPT
- 22:34model and this little handout we
- 22:37hope will be helpful to you to
- 22:40go through the steps of ADAPT.
- 22:47All right. So does everybody feel ready to
- 22:51practice using the ADAPT model, following
- 22:54that little description of the ADAPT?
- 22:59So here's what we're going to do.
- 23:00We're going to have you all go into breakout
- 23:03rooms for a duration of 15 minutes and
- 23:06we'll have three people in a breakout room.
- 23:09We're asking one of you to
- 23:12be the giver of feedback,
- 23:14a second person to receive feedback,
- 23:17and a third person to be the observer
- 23:20who observes the feedback conversation.
- 23:22And also that person will be the observer,
- 23:25will be the one giving feedback
- 23:28on the feedback.
- 23:29So we'll have you do that
- 23:31after watching this video,
- 23:32which we will show you shortly.
- 23:35And in the video,
- 23:36you will see a medical student.
- 23:38You'll see an attending who's
- 23:40observing in that video.
- 23:42And then you'll see the
- 23:44patient and his partner,
- 23:47the shared goal that the teacher
- 23:50and the student have come up with
- 23:52for the purposes of feedback.
- 23:53Conversation is shared decision making.
- 23:56So as you watched the video,
- 23:58use the handout that we just
- 24:01posted in the chat.
- 24:03Think about what reinforcing or positive
- 24:07comments you might give the student.
- 24:10Think of yourself as the attending.
- 24:12Think about what constructive
- 24:14comments you might give the student.
- 24:17And then for those who might
- 24:19eventually in the breakout rooms
- 24:21with the giver of feedback,
- 24:23utilize that handout,
- 24:24the adapt handout to go through all of the
- 24:28steps and give feedback to the learner.
- 24:30So one person will play the role
- 24:31of the attending,
- 24:32who's the feedback giver,
- 24:34the second will be the student
- 24:35who will receive feedback,
- 24:37and the third will be the observer.
- 24:42Alright, can we share the video?
- 24:49So don't go just yet because we're
- 24:51gonna sorry I opened one prematurely.
- 24:53Watch the video first, please. Thanks,
- 25:00everybody. Before we start the
- 25:02video though, does anybody have any
- 25:04questions about what we're doing here?
- 25:09All right. So we're just watching
- 25:11the video and thinking about what
- 25:13feedback we might give that student
- 25:15who you will see speaking in the video.
- 25:18Thank you. Thank you.
- 25:19Linda, I think you can start it now
- 25:24so we don't hear the volume.
- 25:26I'm not sure if I'm the only one.
- 25:33So Karen, would you mind?
- 25:35So we think that might be a place for
- 25:39us to start. So Karen, would you mind?
- 25:41So we think the cause of your
- 25:44symptoms is something called
- 25:46benign prostatic hypertrophy,
- 25:48and this occurs when the prostate enlarges.
- 25:50This can be due to a variety of factors,
- 25:52including your own endogenous testosterone.
- 25:55And what happens is that as it enlarges,
- 25:57it pinches the urethra and so you have
- 26:00a difficult time emptying your bladder
- 26:02and your urine stream is thinner.
- 26:04Other more rare causes of your symptoms that
- 26:07would be much less likely include prostate
- 26:10cancer and also a neurologic condition.
- 26:12But we don't think that's
- 26:14what's going on here.
- 26:16So let me tell you about
- 26:17what we can do about it.
- 26:18There is a very common surgery that's done.
- 26:21It's called a transurethral resection.
- 26:23And what the surgeon would do would be
- 26:25to go up through the penis and remove
- 26:27part of the prostate and that would
- 26:29relieve the pressure and allow you to,
- 26:32this is a very safe surgery,
- 26:33nothing to worry about,
- 26:34but we don't think you need it
- 26:36right now because you haven't tried
- 26:38medication yet and medications really
- 26:39the first line of treatment for this.
- 26:41So what we wanted to do is start you
- 26:43on something called an alpha block,
- 26:45and what that's going to do is
- 26:47relax the muscles of your urethra
- 26:48and allow you to urinate.
- 26:49There's one major side effect that
- 26:51you want to be looking out for,
- 26:53and that's orthostatic hype of tension.
- 26:55So you'll need to give us a
- 26:56call if you feel dizzy.
- 26:57Otherwise it can cause dry mouth
- 26:59and very rarely allergies.
- 27:01But we think you're going to do fine
- 27:03on this medication in the future.
- 27:05There's another medication called the
- 27:065A reductase inhibitor and that would
- 27:08actually shrink the size of your prostate,
- 27:10but it has some negative side
- 27:12effects like a loss of libido or
- 27:14the inability to hold an erection.
- 27:15So we're going to hold off on this.
- 27:18And then of course,
- 27:18there's always the option of doing nothing,
- 27:20but it sounds like you're
- 27:21too uncomfortable for that.
- 27:22So we would recommend it.
- 27:24So,
- 27:24and finally,
- 27:25the last thing we want to do before
- 27:27you go today is get a urinalysis
- 27:28just to make sure you don't
- 27:30have urinary tract infection.
- 27:31Could my husband really have prostate cancer?
- 27:35And we had a dear friend who
- 27:37recently died of it and he had the
- 27:39same symptoms that my husband has.
- 27:41I'm just worried sick about this.
- 27:43Do you think we ought to see a specialist?
- 27:46So we're gonna do a blood test for
- 27:49prostate cancer called the PSA test.
- 27:51I know we've given you a lot
- 27:52of information today,
- 27:53and so I think it's best to just
- 27:56take things one step at a time.
- 27:57First, the blood test for prostate cancer,
- 28:00Also the urinalysis.
- 28:02And we'll give you a prescription
- 28:04for telmisart.
- 28:05OK.
- 28:06Yes,
- 28:06sounds fine,
- 28:09Karen. Thank you very much for that
- 28:11explanation. I think we've given
- 28:12you a lot of information today
- 28:15and I'd like to begin by talking
- 28:16about a few other things.
- 28:25Alright. Thank you, Linda.
- 28:27So we'll go into our breakout
- 28:29rooms again in groups of three.
- 28:32Pamela, do you have a question?
- 28:34I do. When we break out the student
- 28:36is going to, I'm a little confused
- 28:40about. It's very clear the attending
- 28:41can give feedback in the observer,
- 28:43but the role of the student,
- 28:45is it from the video or from
- 28:48I'm confused about the student.
- 28:50Where's the student getting their info?
- 28:52Right. The student is the student
- 28:54in the video, so the feedback
- 28:57will sort of role role plays.
- 29:00The student and receive feedback from the
- 29:03attending will be the giver of feedback.
- 29:07You can use your handout for adapt to help
- 29:09you go through the different steps of adapt.
- 29:12We have a second handout that
- 29:15has listed the questions that
- 29:17are in each step of the ADAPT.
- 29:20So if you want to refer to that,
- 29:22that might be helpful.
- 29:23And then you have about 15 minutes
- 29:25in your breakout rooms.
- 29:27So that initial feedback conversation
- 29:29might last for 7-8 minutes and then
- 29:31the observer giving feedback on the
- 29:33feedback might be the rest of the time.
- 29:35If you have extra time left over,
- 29:38certainly the student who was the
- 29:40observer can also practice giving
- 29:42feedback and we'll try to pop into your
- 29:45your breakout rooms as well so that we
- 29:48can help you along with the process.
- 29:50And
- 29:50again yeah sorry I was just gonna
- 29:53say often when you're busy like and
- 29:55the breakout session part comes,
- 29:57you leave the meeting.
- 29:58Please don't take a chance to take a
- 30:01take a moment to do this together.
- 30:03It's 0 stakes environment in which you
- 30:06can practice a skill that is very useful.
- 30:08So we hope you stick around.
- 30:10Yeah. Thank you. Thank you,
- 30:11Susan, for that reminder.
- 30:13And one more reminder that the
- 30:15goal that you came up with the
- 30:18student to have that feedback,
- 30:20conversation on is shared decision making.
- 30:23So that that's the goal
- 30:25that that was decided upon
- 30:27exactly. And try not to get into the
- 30:29content because as an internist there
- 30:31are so many things that are not right
- 30:32in terms of what's being said that's
- 30:34not really don't focus on the content,
- 30:37more on shared decision making in
- 30:39the process of giving feedback.
- 30:42All right. So Reagan or Linda,
- 30:45if you could open the breakout rooms,
- 30:47they are open and everybody can
- 30:49feel free to go in their rooms.
- 30:56Welcome back, everybody.
- 30:58So First off, I want to apologize.
- 31:00I know there were some of you who
- 31:03didn't get a chance to watch the
- 31:05video and went into breakout rooms
- 31:07before we were able to do so.
- 31:10But nonetheless,
- 31:11I appreciate that you all were
- 31:14still having conversations in
- 31:15your breakout rooms about some
- 31:17of the the aspects of feedback
- 31:19that we brought up earlier.
- 31:23No, actually can we just have no slides? And
- 31:28sure, yes, I will see each
- 31:31other better. I like that.
- 31:34Yeah. So just wanted to open this
- 31:36up for some initial reflections.
- 31:42What was easy?
- 31:43Was there any part that might be
- 31:47difficult when you were having this
- 31:49conversation and using the ADAPT model?
- 31:51And please feel free to unmute yourselves
- 31:54and and speak or put in chat as well,
- 31:58whatever you prefer. Hi,
- 32:00this is Khushboo.
- 32:01I'm internal Medicine from Southport.
- 32:03We were doing our small group discussion
- 32:05and we breaked out before we could
- 32:08have more detailed discussion.
- 32:09But the person who was the
- 32:11attending was Charlotte.
- 32:11She was excellent.
- 32:12She did the ADAPT model.
- 32:14But my question is when we are
- 32:17about to discuss and give feedback,
- 32:19this particular attending chose
- 32:21to ask the student.
- 32:23May I give you some feedback?
- 32:25How do other attendings
- 32:26approach giving feedback?
- 32:27Do they get permission from the student?
- 32:29Is that a good idea?
- 32:31Is there any other way of
- 32:33getting into it smoothly?
- 32:39I usually just say is this a
- 32:41good time to give feedback
- 32:42rather than do you you want to feedback?
- 32:45Is this a good time?
- 32:46So I I always say yes,
- 32:49we're going to give you feedback
- 32:51is but you know are you,
- 32:52are you willing to accept it?
- 32:55And I would say I heard this come up
- 32:57in the group that I joined laying
- 33:00the groundwork for that in terms
- 33:02of saying we're going to be doing
- 33:04feedback a lot during this rotation.
- 33:06It's goes both ways.
- 33:07Let's make sure that we,
- 33:09you know if you have things
- 33:10that that you noticed,
- 33:11please tell me and I will tell
- 33:12you at the time that I see it.
- 33:14So don't be surprised.
- 33:15So kind of laying that
- 33:17groundwork can be helpful.
- 33:18And then also just having that
- 33:19awareness that there are times
- 33:20where it's even though it's timely,
- 33:22it's not a good time to give feedback.
- 33:23So if someone is looking like
- 33:25they haven't slept for 25 hours,
- 33:28they're probably not going to be
- 33:29able to take that feedback, right?
- 33:31Thank you.
- 33:33Yeah, definitely. I mean,
- 33:34having that situational awareness
- 33:36is important, but at the same time,
- 33:38it's also important to normalize
- 33:40the process of feedback.
- 33:41So rather than asking permission for whether
- 33:44we can have a feedback conversation,
- 33:47I I like Scott. What you mentioned
- 33:49in terms of sort of asking,
- 33:51is this a good time for feedback?
- 33:52But the more you normalize it,
- 33:54the easier it will get and it
- 33:56will lay the foundation for your
- 33:59ongoing longitudinal feedback
- 34:00conversations because that's that's
- 34:02what the goal is going to be.
- 34:04One of the things that Doctor Kron
- 34:06brought up in the breakout room was
- 34:08how do you address the power dynamics
- 34:11when it comes to having a feedback
- 34:13conversation and how does that creep
- 34:16in to when we're having that dialogue?
- 34:19Would love to hear any reflections
- 34:21or thoughts from the group.
- 34:26Erin did a really great job in our
- 34:28group because she used the word we,
- 34:30which implied A collaboration,
- 34:32especially toward the end of our discussion.
- 34:35And I think that's a very effective
- 34:37word to use the word we in our
- 34:39feedback with our students.
- 34:42Yeah, that's excellent.
- 34:43Another thing that I've found to be
- 34:46helpful when you're trying to minimize
- 34:49the power dynamics is also being open
- 34:52to receiving feedback as an attending
- 34:56and also discussing it right at.
- 34:59So for example in GI clinic at the beginning,
- 35:03I'll say you know that's great.
- 35:05I'm glad you're joining me in clinic today.
- 35:07At the end of clinic we're
- 35:09going to do some feedback.
- 35:11I'm happy to receive any feedback
- 35:12that you might have for me as well.
- 35:15And please tell me if there are
- 35:17things you want me to continue to do,
- 35:19things you want me to do better,
- 35:21and if there are things that
- 35:23are working for you or things
- 35:24that are not working for you.
- 35:26So it allows the trainee to realize that yes,
- 35:29I'm gonna give them feedback,
- 35:30but I'm also open to receiving that.
- 35:35I think that's this is all quite good.
- 35:39I like the idea. Is it James of using
- 35:44we statements and being inclusive?
- 35:48Sometimes I've gone a step further and
- 35:51say you know we're all working together
- 35:54as a team and we're most effective as a
- 35:57team if we're honest with one another.
- 35:59So feel free to talk up and share your
- 36:03feedback with me and that way will
- 36:06be a success together or something
- 36:08along those lines that that may
- 36:11not have been the absolute best,
- 36:13but you see what I mean?
- 36:19That's a great learning climate
- 36:21where people feel comfortable
- 36:23exactly. So it's that feedback stool
- 36:25where one of the legs of that feedback
- 36:28stool is the learning climate.
- 36:30And the more time you spend in
- 36:33building that climate that the harder
- 36:35and easier it will be for you to
- 36:37sit on that that feedback stool,
- 36:39the other legs being goal setting
- 36:42as well as having that dialogue.
- 36:46I think it's rare that we interact
- 36:48with students or with colleagues
- 36:50or that we don't learn something.
- 36:52And so I think it telling
- 36:54the student what I learned,
- 36:57like if there was something they
- 36:58said this would be helpful for me.
- 37:00And I I think it's great to be able to say
- 37:02to them you know what that's a great idea.
- 37:05I think I'm going to incorporate
- 37:06that in my practice too.
- 37:08And so I feel like that's it's is transparent
- 37:12and it builds confidence and it's good.
- 37:15It's something that I can use telling
- 37:17them that there's something I can use
- 37:19as opposed to giving a laundry list
- 37:20of these are all the opportunities
- 37:22for you to improve yourself because
- 37:24you are in the if they're learning.
- 37:27So they're obviously going to be
- 37:28trying to improve themselves.
- 37:30But yeah,
- 37:32that's that was sort of something
- 37:34that came up in our group is sort of
- 37:36if the student reveals something,
- 37:38say, you know what,
- 37:39that's that's pretty sharp.
- 37:40I'm gonna, I'm gonna use it.
- 37:41I'm gonna adopt it if it's,
- 37:43you know, if
- 37:46you don't mind or even a
- 37:47phrase that you wanna steal.
- 37:49No, that's perfect.
- 37:51Thank you. All right.
- 37:53So I think we'll move on.
- 37:57Susan, did you wanna pull
- 37:59that presentation back up?
- 38:35I'm so good at Zoom.
- 38:36Takes me 10 times longer than it should.
- 38:39So. So in summary, we're hoping
- 38:43that you will consider using
- 38:45the ADAPT model for a feedback
- 38:47conversation that incorporates
- 38:49the learner's self-assessment and
- 38:51readiness and addresses modifiable
- 38:54specific behaviors and helps them
- 38:57develop strategies for improvement.
- 38:58So those those are the really the
- 39:01basic premises as opposed to just
- 39:03out output of of things that you
- 39:06think that they could do better.
- 39:08So what we would love to do is
- 39:11hear first of all if you could
- 39:14do the evaluation feedback.
- 39:16This is will take a minute for
- 39:18you to do that and then we will
- 39:21open it up to more questions.
- 39:33Keep it specific, modifiable.
- 40:10All right, so while you finish doing that,
- 40:12we would love to hear any questions
- 40:15or comments that you have or things
- 40:17that you will be taking away from
- 40:18this session to use in your practice.
- 40:25A quick question,
- 40:27how how would you recommend
- 40:30dealing with apathy?
- 40:34So you're you're trying to give
- 40:36feedback, you're trying but
- 40:38you you're kind of stuck or
- 40:39or hitting a like a brick wall or or.
- 40:42And I know a lot of it has to do with
- 40:45what Doctor Patak was talking about
- 40:47reading the environment and kind of you know,
- 40:50is this person open to the feedback.
- 40:51But when you do encounter
- 40:53that that situation,
- 40:55what what would your recommendations be?
- 40:59How do you? Great question.
- 41:01Yes, great question.
- 41:02So there are definitely challenging
- 41:04feedback situations and we can
- 41:05talk about that for just a moment.
- 41:06I will share my screen and
- 41:12OK, so in the interest of time we
- 41:15didn't really get into this and
- 41:16hopefully we'll have a session
- 41:18delving into this more in the spring.
- 41:20But for either learners who lack insight or
- 41:23appear defensive or this professionalism,
- 41:25or learners that don't integrate feedback,
- 41:27it can be more challenging.
- 41:29But some of the basic steps are to
- 41:31really approach it with appreciative
- 41:32inquiry like try to understand it
- 41:34may seem like they're apathetic it
- 41:36there might be something else going
- 41:38on and really try to build that
- 41:42relationship and and and try to
- 41:45find out their perspective on it and
- 41:49then be really behaviorally based.
- 41:51So, so you know when you are on your
- 41:55phone during rounds the perception
- 41:57can be that you are not interested or
- 42:01you know when you when you look away
- 42:05when a patient is talking to you,
- 42:07the perception can be that you're distracted.
- 42:10So really trying to go behaviorally
- 42:14and then try to emphasize the impact
- 42:17that that has on other people,
- 42:20so especially their patients and try to.
- 42:23And sometimes it can be helpful in
- 42:26those situations to get trusted
- 42:27mentors to be part of it.
- 42:29Maybe they're not hearing it from
- 42:31you or they're not able to take that
- 42:33feedback from you at that point.
- 42:35And it might require multiple conversations.
- 42:39So those are some of the things
- 42:41that that can be helpful.
- 42:43Any other ideas from others say
- 42:46actually I think that the apathy.
- 42:49I feel like this is what I used to
- 42:51do before I was when I was like
- 42:52more performance oriented until I
- 42:55switched to more learning oriented.
- 42:57As a human, I just feel like apathy
- 43:00is a defense mechanism to try to
- 43:02take the feedback without reacting to
- 43:03it. And I feel like it would have been
- 43:06helpful for me like a while ago if
- 43:10the person giving me feedback had circled
- 43:12back like a couple days later.
- 43:13Because often people who get that feedback
- 43:15that way need a couple days to like,
- 43:17process it and think about it.
- 43:19And I think circling back is often
- 43:21very helpful to say like hey,
- 43:22I know we talked about some
- 43:24feedback the other day.
- 43:25You know you've had a little
- 43:26time to think about it.
- 43:27Anything I could help
- 43:28you with to reach your goals
- 43:30or to make that feedback,
- 43:32you know, something useful for
- 43:33you as you grow in your career,
- 43:35something like that,
- 43:36that's more like team based and
- 43:38supportive Because I I think it
- 43:39really is just helping someone
- 43:41switch from a performance oriented
- 43:43to a learning oriented mentality.
- 43:45And I think that that really helps
- 43:46shepherd that a little bit forward.
- 43:49But that's just my experience.
- 43:51Yeah, that's fantastic. Thank you.
- 43:55And kind of as a way of
- 43:56operationalizing that,
- 43:57sometimes I find it helpful to
- 43:59like have an index card for the
- 44:01learner when I'm going on on a
- 44:03service where we first have that
- 44:04conversation of what are your goals.
- 44:06And I write down their goals and I try
- 44:07to get them to be specific so that
- 44:09we've made kind of a pledge to each
- 44:11other that we're working on that.
- 44:12And then when we have feedback conversations
- 44:15or or if I'm observing something,
- 44:16just making columns of like reinforcing,
- 44:18correcting corrective feedback
- 44:19so I can remember that even if I
- 44:22can't give the feedback right then.
- 44:24So if they are leaving overnight and you
- 44:26know, there's just no time to do it,
- 44:28I'll say, hey,
- 44:29can we talk about a few things
- 44:31tomorrow about about this encounter
- 44:34and then go through it then?
- 44:36And that allows me,
- 44:38even though I'm absentminded,
- 44:39to try to remember what it is that
- 44:42we talked about so we can revisit
- 44:43it in like mid, mid,
- 44:44rotation feedback and end of
- 44:46rotation feedback. How's that going?
- 44:48What can we be doing better
- 44:49to achieve your goals?
- 44:50What other goals do you have?
- 44:56Susan and Uma.
- 44:57It's after one though it seems
- 44:59like people are happy to chat,
- 45:02so I know that I'm able to stay on.
- 45:04But those of you who need to hop off, great.
- 45:07If you wanna stay a few more minutes,
- 45:09I'm able to stay.
- 45:10I don't know if you,
- 45:11Uma and Susan could stay
- 45:13for a couple more minutes.
- 45:15Absolutely. And I really appreciate
- 45:17everyone's attention and
- 45:18engagement today. Thank you. Yeah.
- 45:20Thank you very much, everyone.
- 45:24One thing that so I popped into
- 45:27the room that James was in as the
- 45:31student and one thing that I really
- 45:34liked about James role as the student
- 45:36is he really paid attention to the left
- 45:39hand side of the ADAPT model and you
- 45:41know ask some really pertinent questions
- 45:44so took an active role as a learner.
- 45:46So I thought James you demonstrated you
- 45:49know how that should go on the side
- 45:51of the student if they're not exactly
- 45:54getting you know the feedback that they need.
- 45:57I mean, Aaron was doing a great
- 45:59job in giving what he needed,
- 46:01but he was also very specific
- 46:03about some questions.
- 46:04So I thought that was great.
- 46:11Any other takeaways, things that
- 46:12you might want to incorporate?
- 46:18I think this is all very valuable
- 46:20and I will definitely carry
- 46:21these lessons with me as I see
- 46:23as I see students and patients.
- 46:24Thank you very much.
- 46:26Thank you very much.
- 46:29Please don't hesitate to reach out to us,
- 46:31e-mail us if any questions come up
- 46:33because this was just an initial sort of
- 46:36snippet into the conversation of feedback,
- 46:38but there's so much more beyond this.
- 46:44Gonna sign off. Thanks again.
- 46:45Thank you. Nice seeing
- 46:46you guys. Bye, bye. Bye.