So, some of you have heard of the feedback sandwich. The feedback sandwich is such that there's an area of good, followed by the meat, followed by a good. Some people believe that the feedback sandwich is an effective way of providing feedback. I'm going to kind of argue against that, and I'll, propose a different model for it. But let me just be a little bit clear about what the feedback sandwich is. I had a chair who used to provide feedback in this way, and every time I met with him, he would say first, oh, Sally you're the best clinician that we have. And then there would be the meat of the matter, which was that I had clearly done something that had dissatisfied him that he did not think was adequate. And then at the end he always said, and I want you to take care of my family. So for a period of 13 years, I received many of these feedback sandwiches. The good was always, you're great clinician, and the at the bottom was that I want you to take care of my family. But the meat was really where it was. And so the good really felt disingenuous. It didn't feel genuine and so I just waited for the good. because I knew it was always the same. And waited for the meat which is what he really meant to say. And I knew that at the bottom of I want you to take care of my family was just not really genuine about what he meant. What he meant was the meat, and so the problem with the feedback sandwich is that if you use it all of the time, and the expects us to come, they know that good isn't really meaningful, but that the meat is where it is. And so the important thing is to try to make it a balanced integrated approach, and more of a conversation rather than good, bad, good. And so I'm going to propose this four step feedback model. We're going to go through the steps, and then I'm going to go through each of the steps in detail so you have a better sense of what they look like. The first one is to prepare. The next one is to elicit the learner's input, that's their self-assessment so that they know where they're coming from. The third one is to have a conversation. Discuss the performance, provide the feedback, and we'll go into more details about that. And then finally you need to conclude with an action plan or a plan for improvement. So, let's go through each of these steps. The first one is to prepare the learner to receive feedback. The most important thing here is to decide what are your objectives for their performance? What do you want them to change? If you don't have a sense of what they've done wrong and where you think they should go, and how they're going to get there, then you're probably not going to have much success with the feedback that you provide. So think very clearly about what are your objectives. I'm going to refer forward to the to the spinal tap video where the, learner, doesn't use sterile field, doesn't use enough lidocaine, is rather mean to the patient. When you provide feedback for this video, it's very important to decide what are your objectives of this. They can't be too broad, they need to be specific, but they need to be very intentional about what you want. So first, before you provide feedback, think about what are your objectives? The next thing is that you should make it expected. As I told you about my ritual for providing feedback. I always provide it at the end of the shift. About an hour before the end of my shift we provide feedback. And it's gotten to the point that sometimes the learners or the residents will look at me and say, okay. How did I do today, how's my feedback, and we'll go ahead and do it. So make it expected, make it part of your ritual and your routine so that they know that this is feedback, and they know to expect it, and it doesn't come as them as a surprise. It's funny, in our residency, some of the things that we're concerned about it is that when we say we're going to give feedback, the residence are interpreting it as a negative thing. Because it's unexpected, it must mean that they had done something poorly. If we made it expected all of the time, we always provided feedback then we would probably do a better job and that they would be expecting it and doing better with it. The next thing is that it needs to be private. Don't do this in a public place, nobody wants to be shown up in front of their colleagues. Step aside and make it private. Take the time and the effort and show the committment by making it private. The next thing is, that it needs to be timely. It needs to be relevant, and timely, in time to when they did the performance, and not a week later or ten days later, or whatever. So make sure that it is timely. The next thing is, say the word feedback. It always feels kind of weird when we do that, and I confess, what I usually do is, I'll say, oh, is it time for feedback, or, because I'll say something at the end of whatever feedback I'm providing, such as, was that good feedback? That lets the learner know that this was intentional feedback. And that may help the disconnect between when faculty think they are giving feedback and when learners think that they are getting feedback. The next piece is learner input. And here it's really important to know what the learner thinks that they did. Remember our little wolf here who thinks she's a big wolf. Our learners don't necessarily know what they did or how they did. But the only way that we can provide feedback is to be able to understand that. Remember when we talked about confirming and disconfirming feedback? The purpose of the learner input is so that I understand what they think they did. If their self assessment is relatively correct and the feedback that I'm going to provide is confirming, then I have actually got half of my work done. My work is simply to then think about a plan about what to move forward. If their self assessment is like Kruger and Dunning and they think they're above average when in fact they were not, then I know that the time that I spend on my feedback will be need to be directed at trying to get a better informed self assessment of how they did so that they can understand and move forward. So, there's some questions that you might ask are, what did you learn today? How do you feel that you did? How did that scenario go? How did you feel like you communicated with the nurse? What do you think you need to work on? What are your strengths? And these are things that might get you to how they feel that they did today so that you can then provide the feedback that is, that is necessary. I know I keep using the word provide feedback. I don't really mean it like I'm going to give them feedback. What I really mean is that you're going to have a conversation and this moves us on to step three. Step three is having a conversation. This is where you're going to have a conversation about what you perceive that they did, why they did it. Those sorts of things. But it should really be a back and forth. It should not be me just telling them, or me providing feedback. It should be trying to get them from that confirming to plan, or from disconfirming feedback, to actually agreeing with what I saw, or what I think I saw. So that they can move forward with the the plan. These should be based on data specific actions and changeable behaviors. You need to provide concrete examples, so that if you're concerned about this issue with the nurse, you might say, did you notice that you were very short with the nurse, and she turned around and didn't listen to what you had to say? So provide concrete and real examples, so that they can understand how their performance is seen. It's also important to provide feedback on both good and bad behaviors. If it's all negative, then there's going to be just kind of the sense of futility on the part of the resident. In the sense so that they can't do anything right and they also probably will not find you to be particularly credible. Most people do something both good and both bad in the domains that they're working in. And so try to find something during this conversation that reinforces the good behavior, but then tries to address the negative behavior, so the behaviors that you want to be improved. This is the conversation and this is kind of the meat of the matter. The next thing is that you need to agree on a plan for improvement. It is best if it comes from the learner. Remember at the very beginning we said that people remember 90% of what they do for themselves, what they say or do, and 10% of what you tell them. So if you tell them, I think you need to do x, y, and z, it is less likely that they won't either do it or remember it. It is better if they come up with things for themselves. So, questions such as, how much you do this? What might you do to improve this? Or, how am I to approach this a different way so that they're finding their own way and answers to things? Is going to lead to better improvement and better performance in the long run. Occasionally you might suggest ways to improve. You might give consequences, for example, on the issue with being stimpy with the nurses. I know that the nurses save me every day, and that I rely on them because they are at the bed side and understand what's going on. And so one of the consequences of being stimpy with the nurses is that when she notices that my patient is decompensating, or she notices that I have made an error, she may not come to me. So make sure that they understand the consequences of things that they're doing. That will help to motivate for improvement. And then in the end on this plan for improvement, make sure that you confirm understanding, that in the end, both of you walk away with, I know that this is what the issue's for, I know that this is what I need to continue to doing, keep doing, and I know that this is what I need to change. And confirm the understanding and plan. Like with setting goals, it's important to have that be kind of timely, and have a time definition to it. So that the next time that you work with that resident and you see that resident, that you're confirming that they've actually done what they said their were going to do, and that they know that there is that sort of a, an understanding or an expectation that they'll do that for the next time. So these are the four steps for feedback. First, prepare the learner to receive feedback. Ask the learner for their own input, so that you've got a sense of their own self assessment. Have that conversation. The conversation is the key to this. It should be both including performance that they want them to get me to do, as well as things that you want them to improve on. But it should be a conversation with hopefully the learner, saying and directing where it's going. And then finally agree on a plan for improvement. Remember this is not a hierarchical plan, it should come from the learner, so that they know what they're going to do and how they're going to improve. And finally set a time about when you're going to check back with them to make sure that they've done the things that you hope that they do. So our next segment is to look at some videos. I'm going to show you some videos of some learners doing various performance, and I'm going to ask you to provide feedback on these videos so that you can practice your steps for feedback. Remember the steps. Go back to the outline if you feel like you need it. First decide what you're going to do, right? So that's the objectives. What am I going to give feedback on? You're then think about how you'd provide a learner input. And then have a conversation of what you would say to this learner, or how you would converse with this learner. And then finally agree on a plan for improvement. So they, you end the session with how they might improve. All right, let's go on to the videos.
