October Faculty Development: Giving Difficult Feedback

Giving Difficult Feedback by Dan Pitts, MS4

Giving appropriate feedback to students can help them overcome their problems and allow them to successfully progress in their medical education.

1. There are four classes of problems, as defined by Vaughn.

1. Affective – Feelings of low self-esteem, anxiety, guilt, depression. May be related to stressors such as illness in the family, adapting to clinical rotations or even stress from poor performance.
2. Cognitive – Poor fund of knowledge or integration of knowledge, difficulty with written or oral communication. These may reflect learning disabilities.
3. Structural – Difficulty with organizational skills and time management.
4. Interpersonal – Difficulty interacting with others including patients, staff or faculty. May be shy or overeager.

2. S-T-P model for giving feedback:

1. S = Specify The Problem:
   Classify the problem by the categories above, and specify in what ways performance is below expectations. Is the difficulty specific to a specific situation (learner does not understand the physiology of calcium homeostasis) or present across all settings (learner is frequently texting with friends)?
2. T = Target State:
   Collaborate with the student and generate ideas of how a realistic target state might look. When possible, enable the student to contribute Example: “What do you think you need to know about hypocalcemia?”
3. P = Procedure, Plan, or Path:
   Work together to develop a comprehensive plan of action, and be sure to follow up. Follow up with the learner is crucial. It is reasonable to involve specialists if the problem requires, such as a counselor or therapist if the problem is substance abuse. Be sure to follow up!

3. More tips for giving feedback:

1. Don’t overload the session:
   Learners can only assimilate so much at once. When choosing what to address, a good place to start is with behaviors that directly impact patient care.
2. Specifics are important for positive feedback too:
   Saying “good job on that case presentation” is not as helpful as, “your case presentation concisely elaborated the pertinent positives of the patient’s condition and you provided a thorough differential diagnosis for the patient’s cough.”
3. Focus on behaviors and use “I” statements to depersonalize difficult feedback:
   Saying, “I have noticed you texting frequently, which makes me wonder if you are disinterested” sounds like less of a personal judgment than, “you seem disinterested,” AND it describes a specific behavior that can be corrected.

_{References: Vaughn, LM. Baker, RC. DeWitt, TG. The Problem Learner. Teaching and Learning in Medicine 1998; 10(4): 217-222 Ende, J. Feedback in Clinical Education. JAMA, 1983; 250(6): 777-781}