James C. Etheridge, MD
Resident in General Surgery
Brigham and Women's Hospital
PGY 3
03/03/2021
 |
Students in the Introduction to Clinical
Medicine Course |
Despite a strong feedback culture in the Brigham and Women’s
General Surgery Residency, many medical students report that they would benefit
from improved feedback from their surgical preceptors. The Clinical Teaching Skills course provided
a set of tools to improve the quality and utility of feedback.
As a preceptor for the Harvard Medical School Introduction
to Clinical Medicine course, I routinely ask students to assess themselves and
seek feedback from their peers before sharing my own feedback. Results have been mixed. Many students find it difficult to identify
specific, actionable areas for improvement.
It is particularly difficult for students to communicate “negative”
feedback to their peers.
The Clinical Teaching Skills course highlighted three
structured feedback instruments I have found particularly useful. These instruments provide a shared language
for us to assess each other. They also
help to “depersonalize” constructive feedback: the feedback technique provides
a sort of buffer, making it easier to both give and receive feedback without it
feeling like a personal attack.
We first introduced the Plus/Delta feedback tool. After every patient presentation, each
student now identifies a few areas where they performed well and a few areas
for improvement. Their peers then
supplement this self-assessment with their own observations. The quality of peer feedback has improved
immeasurably. Instead of “you did very
well” or “I could have done better,” I now commonly hear specific, actionable
points from each student. “I think I get
all the information I need in the HPI, but I have trouble organizing it
linearly,” or “you did a great job describing the abdominal exam, but I don’t
think it was necessary to describe the whole neuro exam” are some recent
examples.
I also started using the Advocacy-Inquiry method when
observing physical exams. “I noticed
that you were struggling with the abdominal exam,” for example, can be followed
by “it seems like it would have been easier if you asked the patient to get
back in bed. Why did you try the exam
with the patient in a chair?” This
allows the student to share their thought process. Perhaps they knew that the patient requires a
two-person assist to get back in bed.
There may be a perfectly reasonable explanation that would be lost with
unstructured feedback such as “you should have performed the exam with the
patient supine in bed.”
We are now experimenting with the R2C2 feedback model. This approach has been shown to improve
feedback assessment and promote coaching.
In the first stage, we build rapport.
This is largely accomplished through our longitudinal relationship, one
of the strengths of the Introduction to Clinical Medicine course. However, we also take time to discuss matters
of interest or concern to the students at the beginning of each session. Topics have ranged from humanism in medicine
to dealing with hierarchy in the workplace.
We then explore reactions to feedback.
Students have generally felt quite positive about their feedback,
particularly constructive feedback. This
may reflect their preexisting growth mindsets, but I believe the feedback
techniques mentioned above reinforce this mindset. By exploring the content of their feedback,
we can identify specific areas of concern for the student. Perhaps the peripheral vascular exam has been
a challenge. Perhaps they struggle most
with organizing the HPI or coming up with a plan. Without exploring areas of greatest concern,
it is impossible to accomplish the next step: coaching for change. We develop an individualized plan for each
student, complete with a “check-in” point to promote accountability. Plans may center on additional physical exam
practice, making effective use of written notes, organizing a plan by systems –
regardless, it is critical that these plans are co-created with the student.
Responses from the students to these feedback instruments
have been glowing. Anecdotally, I have
observed rapid improvements in their clinical skills over a very short
time. From a purely selfish perspective,
using these feedback tools has made my job as a preceptor easier. The cognitive load of assessing and providing
feedback is lessened considerably just by using these frameworks.
Certainly, the insights I gained from the Clinical Skills
Teaching course are not limited to feedback techniques, and I will leverage all
of these lessons to the best of my abilities.
However, learning these feedback methods has been the most meaningful
and relevant element for me and will continue to serve me well throughout my
career as a medical educator.
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