#1 Optimize your Feedback Conversations

December 14, 2021 | By Molly Heublein

With Dr Calvin Chou

Summary

Listen in as expert Dr Calvin Chou (UCSF)  leads us through concrete tips to optimize your feedback dialogue with learners.  We cover the importance of creating a relationship built on mutual goals of getting to our personal best, helping learners form SMART goals, the ARTful approach to a feedback conversation, ways to minimize bias, and you even get to hear Era role play!

Claim free CME for this episode at curbsiders.vcuhealth.org!

Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!

Credits

• Infographic: Andrew Delaat 
• Hosts, producers, writers:  Era Kryzhanovskaya, MD; Molly Heublein, MD
• Audio Editor: Clair Morgan of nodderly.com
• Guest: Calvin Chou, MD

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments:  

• Intro, disclaimer, guest bio 
• Guest one-liner 
• Picks of the Week 
• Case from Kashlak 
• Definition of Feedback 
• Creating a relationship to give feedback
• Helping learners set goals
• ARTful approach
• Giving feedback on hearsay
• Reducing bias
• Accepting feedback up the hierarchy
• Outro

Feedback Pearls

1. Feedback is specific, non-judgmental information, given in relationship to a standard, with the intent to improve performance.
2. Use some of your already developed clinical skills and frameworks to approach the feedback conversation- “prechart” with your learner to set a goal ahead of time, gather information during the encounter, “chart” learner’s goals, and use teach back at the end of a feedback session to have the learner frame in their own words next steps
3. Reduce bias in feedback by approaching learners with curiosity and an authentic desire to help them do their best. Use empathy liberally!
4. Be open to feedback yourself, it’s the only way we can become our best!

Feedback Notes 

Definition of Feedback

Specific, non-judgemental information, given in relation to a standard, and given with intent to improve performance (adapted from De Ridder 2008).  Feedback is a dialogue, a conversation, part of the educational alliance.  We should not look it as “giving feedback”.  

Setting the Stage

At the beginning of a relationship with a learner, start with a brief conversation to build trust and get to know each other.   You can’t help your learners develop unless you know them.   Ask: “What is important for you in your learning, and what are your goals?”

Dr Chou looks at interactions with a learner almost like a patient encounter- he suggests “pre-charting” with the learner, “What are you working on right now that I can help you with during this clinic session”?  Consider having a “chart” to keep track of the goals over time by writing them down.  Build a therapeutic alliance with the learner as you would with a patient.

Helping learners set goals

SMART goals- specific, measurable, attainable, relevant, and timely.    Help push a learner to clarify a more precise goal if it is too vague.

Learning ladder:

Early learners are in a phase of unconscious incompetence – they may not know what they don’t know.  Consider looking at a list of the course objectives with a learner who is early on and can’t innumerate goals, help them choose what interests them.    

As the learner progresses up the ladder- mid-learners are in a state of conscious incompetence– they know what they don’t know, so are better at enumerating their own goals.  Then comes conscious competence, where learners are aware of all they know and can even better consider next steps.  

Finally we reach a stage of unconscious competence– things become more automatic and so it is easier to move into an automaton space and not improve.  Look for those more advanced learner’s edges and push them to grow.  In high performing learners, think about aspirational goals– what would be their next step forward, how can a third year resident prepare to become an attending.  

Tips for the feedback Dialogue

Remain humble.  Listen with an open heart with the goal of understanding.  Use empathy.  Normalize concerns.

When giving feedback, focus on small chunks instead of big downloads.  Give feedback shortly after viewing the action if possible.  

Try to use a teach-back or take-home point at the end of a feedback session.  Adult learning theory suggests that adult learners do best with internal motivation, so if they voice their own take-home points they are more likely to grow from these.  It becomes an iterative process of the take home points from the last feedback conversation turning into the goal for the next process (Johnson 2016).

Consider using the ARTful feedback framework– Ask, Respond, Teach.

A: “Tell me how you thought that went?” “I noticed you really worked on XXX goal, what did you do effectively?”  

R:  reflect and paraphrase

T: provide your assessment.

Reinforcing Feedback

In early learners, Dr Chou focuses on reinforcing feedback.  In business and marriage, successful teams tend toward a ratio of 4-5  pieces of reinforcing feedback to 1 modifying feedback (Zengar, HBR, 2013).    If you give too much supportive feedback, learners may stop listening as they don’t find it valuable or meaningful; so it’s important to share that modifying feedback as well.

Modifying Feedback

Prepare ahead of time– If you can use school of medicine/course milestones, standards, or competencies and orient your observations to these.  In a learner with multiple issues to address, choose the top one or two things to focus on.  Let the others go or come back to them later.  Don’t overwhelm the learner.

Maintain authenticity and use empathy liberally.  When you are really trying to help a learner, the conversation will go better.

Ask permission- “would you be open to me sharing something that I have seen or that I have heard?”

Giving feedback on professionalism is challenging.    Use reflective listening when the learner’s insights don’t fully align with your views rather than jumping to challenging responses.  If a learner does not seem aware of their limitations, try to be aware of the difference between self defense and lack of insight.

Reducing bias in feedback

Try to avoid giving feedback on hearsay, try to witness the learner directly as much as possible.  

Appreciate that you are coming from your own perspectives, and ask and approach with curiosity and humility.

Be aware of stereotype threat– an anxiety state that one will confirm a negative stereotype about their identity group (Bullock 2020). Validation in the form of reinforcing feedback and high standards can help diminish stereotype threat.

When you’re in the role of a supervisor and need to share this feedback try to gather specifics as much as possible, share how a person is being perceived and gather reactions, rather than jumping to conclusions.  Be aware of implicit bias.    You can ask, “why do you think your actions have come across this way?”  “Why do you think xx person perceived your actions this way? What comes to mind?”

Accepting feedback up the hierarchy

As a supervisor/upper level be aware of the difficulty of feedback coming up the hierarchy.  Be explicit with your learners that you need feedback so that you can grow and improve as well.  Open the channel and make feedback up the channel expected.  If a learner can’t speak directly to their senior/upper-level, they may need to go through or get support from a trusted advocate.

Take home points:

Have a set up conversation and elicit goals from the learner.

Think about feedback as a conversation instead of a download.

Use empathy liberally.

Reinforcing feedback can be a validation for people experiencing stereotype threat or imposter syndrome.

Practicing modifying feedback with a peer ahead of time can help you be read to give that important

Links

1. Cavin’s book recommendation- Nonviolent communication: A Language of Life, by Marshall Rosenberg
2. Avenue Q, Purpose song 
3. Era’s pick of the week: the song Take my Breath, by The Weekend; was not supporting or endorsing the music video which is quite intense. 
4. Molly’s pick of the week: UCSF Women’s Health Primary care is hiring an internist, if you are a passionate clinician educator interested in women’s health, looking to work in San Francisco please reach out to our recruitment coordinator alisa.armstrong@ucsf.edu
5. Schmigadoon on Apple TV
6. Remediation: A Mid-Course Correction by Anita Kalet and Calvin Chou

Disclosures

Dr Chou reports no relevant financial disclosures. The Curbsiders Teach report no relevant financial disclosures. 

Citation

Heublein M, Chou C, Kryzhanovskaya E. “#1 Optimize your Feedback Conversations. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach December 14, 2021.