Feed the Back-Bone of your Skeleton Crew

When we think about education in medicine, the tendency may be to imagine the typical attending/resident model - one attending giving pearls of wisdom to a group of residents on rounds. In reality, teaching is multifaceted and in practice is generally different from this “traditional” model. Residents, not just attendings, are often teachers to junior residents and to medical students. In fact, teaching is one of the ACGME core competencies for residency training.

Feedback is often an overlooked component of teaching and education and how to give effective feedback is not routinely taught, but it is incredibly important. Read on to learn from Dr. Wettasinghe some ways to give effective and constructive feedback to your residents and students.

Feed the Back-Bone of your Skeleton Crew

Tips on Improving Emergency Medicine Resident Feedback

The inherent chaos of a busy emergency department can both create ample situations to learn from while at the same time making it hard to give useful feedback when it's called for. Thoughtful teaching can easily be fractured while caring for multiple undifferentiated patients simultaneously. Teachers want residents/learners to internalize feedback points, to feel it in their bones, but not become spineless. Here’s how:

Be timely, don’t wait until they’re a pile of bones

• Delayed feedback is hard to interpret for the learner. Context is lost, and if they’re unable to recall the situation there is less to learn from.

• Ideally feedback is timed in a way that avoids public criticism but addresses critical actions (intubation technique) in real time.

• Delayed feedback does a disservice by leaving learners to potentially repeat mistakes.

• “You were generally not performing well three months ago” vs. “Let’s talk about your ultrasound technique on this patient we have together”

Be specific, like how you describe fractures to ortho

• Nonspecific and delayed feedback often go together as memory fades. Concise and pointed feedback that occurs while memories are fresh is more likely to address the area for improvement instead of missing the point.

• Telling a resident they need to get better without giving them tools to improve their skills raises questions about how to proceed and decreases feedback effectiveness. Offer ways to improve with negative criticism.

• “Good shift” is an easy light way to give positive feedback, but it’s much less memorable than giving specifics or reinforcing positive behaviors.

• Deliberate practice requires more than simply working harder. Residents often need to work differently to improve. Challenge them to try new methods of managing a busy department, documenting, communicating, and practicing professionalism.

• “You write bad notes” vs. “Your charting is difficult to follow due to redundancies and you can add more time stamps”

Establish Respect and Trust, don’t be occult

• Be professional, a lack of professionalism can cause a lack of respect and trust, leading to feedback being discredited. Praise publicly and criticize privately to promote a respectful workplace.

• Avoid sarcasm and patronizing comments. It’s a skill to get a learner to see things from your perspective. Meet the resident/student where they are.

• Prompting self assessment can help create a sense of autonomy and receptiveness to constructive criticism.

• “That’s stupid, how did you get through medical school?” vs. “I’m going to challenge you because I think you can perform at a higher level.”

Challenges that cut down to the bone

• Critical, bone chilling negative feedback can potentially decrease progress by affecting motivation and confidence. Give tactful non-judgmental feedback.

• Teachers may emulate bad feedback habits from their training, such as reacting in anger or venting to colleagues while avoiding learners. The culture can change.

• For those receiving feedback: Notice defensiveness as a potential barrier to progress. Feedback is more helpful if not taken personally. It’s based on perceptions.

Giving effective feedback is not easy, it’s often uncomfortable, but it’s a skill that can be learned. It’s one of the best teaching tools clinicians have when coaching new doctors. When the opportunity arises, learners will appreciate you throwing them a feedback bone that’s timely, specific, and coming from a place of mutual respect!

References:

Bernard AW, Kman NE, Khandelwal S. Feedback in the emergency medicine clerkship. West J Emerg Med. 2011;12(4):537-542. doi:10.5811/westjem.2010.9.2014

Buckley C, Natesan S, Breslin A, Gottlieb M. Finessing Feedback: Recommendations for Effective Feedback in the Emergency Department. Ann Emerg Med. 2020 Mar;75(3):445-451. doi: 10.1016/j.annemergmed.2019.05.016. Epub 2019 Jul 2. PMID: 31272822.

Ericsson, Anders; Pool, Robert (2016). Peak: Secrets from the New Science of Expertise. Boston: Houghton Mifflin Harcourt. ISBN 978-0544456235.

Rogers, R. L., Mattu, A., Winters, M. E., Martinez, J. P., & Mulligan, T. M. (Eds.). (2009). Practical teaching in emergency medicine. Wiley-Blackwell.

Yarris L, et al. Attending and resident satisfaction with feedback in the emergency department. Acad Emerg Med. 2009; 16:S76–S8.