Testing, Testing… Making Feedback More Than Just Noise

When I give training workshops for the student charity Medsin one of my favourite sessions is conflict resolution. Don’t get me wrong – I am no more capable of giving a solution for world peace in 60 minutes than anyone else. No, I am talking about the dirty, gritty reality that is interpersonal relationships.

Conflict management is a part of everyday life,  from the workplace to home, to our friendships. And while we all roll our eyes and yawn sarcastically when anyone mentions “communication skills”, this stuff really is important. Early, appropriate management can defuse or ignite situations and having the maturity to recognise that a structured and well thought-out approach is needed is a key skill for anyone in the position of educational or clinical supervision.

Conflict resolution and feedback go hand-in-hand; there is an expectation that when you need to give someone feedback, it will be met with hostility and that a conflict could arise (exposing an implicit reasoning that feedback must be negative). The problem is that we often struggle to recognise situations worthy of feedback unless something has gone disastrously wrong. In my head, this seems like an “after the horse has bolted” approach; why don’t we think about feedback before we “really must say something” – and why do we assume that when we give feedback it must be negative?

Why? Because we are (I am) British, and culturally we get terribly flustered when other people do something we perceive as being “wrong”, and we don’t know how to correct it without upsetting people. But as doctors and healthcare professionals, we subconsciously impress our own healthcare standards on our colleagues, and when they fall short (or have a difference of clinical judgement) we feel “duty-bound” to mention it to them, “in the interest of the patient”. We shy away from the opportunity to explore others’ thinking until we feel so emotionally invested in the outcome of it that we have to intervene. Is it any wonder, then, that feedback feels uncomfortable so often?

The problem with this is that so much of Emergency Medicine is subjective. We see a snapshot of a patient’s illness or injury, and make assumptions and assessments based on our knowledge and experience; knowledge and experience which is, by definition, different from our colleagues. Imagine the following situation:

 

In a district general hospital, a trainee has seen a three-year-old child who is non-weight bearing. There is no history of trauma to the leg, but the child appears tender at the ankle. Plain X-rays demonstrate a lucency at the metaphysis. The child is currently febrile with a viral URTI for the preceding week and commenced antibiotics from the GP the previous day. The trainee wonders whether the lucency might represent early secondary osteomyelitis, and refers the child for a specialist opinion.

A written report by a radiologist is sent to the department the following week. The report suggests that the lesion might represent a bucket handle fracture. The X-rays are highlighted to the trainee as “characteristic” and a “missed diagnosis of non-accidental injury”.

 

How might the trainee feel in this situation? Supported? Probably not. Embarrassed? Maybe. Uncertain about their own clinical judgement? Most likely. No-one wants to miss NAI.

Imagine then that the trainee decides to review the discharge letter for the patient – which reveals that there was uncertainty within the admitting team about the diagnosis of non-accidental injury when they had received the report. The films were discussed with regional paediatric radiologists and orthopaedic specialists who felt that the images were more suggestive of osteomyelitis, confirmed with later imaging. How does the trainee feel then? Indignant about the senior doctor’s assumption that their assessment was incorrect? Maligned? But more importantly – how does this affect the relationship between the trainer and trainee?

Rick’s recent post looks at the role of case conferences in improving patient care and identifying areas for systematic improvement. Back in July, Simon looked at the emotional response we look to provoke when discussing clinical errors with juniors; he and I then went on to discuss how to prepare oneself to give feedback.

I’ve been thinking about the feedback conversation itself. What should it contain? How should it be structured? When should it be undertaken? And here’s what I think.

 

Preparation

The most important consideration of the giver of feedback is that it has to be for the benefit of the trainee. Feedback is not to make yourself feel better or to vent your frustrations; it is to encourage development of the trainee. It can be very difficult to make this distinction in the chaotic working environment of the Emergency Department, so I would strongly advocate asking the following questions before allowing yourself to give feedback:

  1. Is feedback necessary on this issue?
  2. Is this the right time?
  3. Is this the right place?
  4. Am I in the right frame of mind to give trainee-centred feedback?
For more on this, listen to the podcast here. Remember, unless the trainee is actively doing something dangerous in front of your eyes, there is rarely a need to give feedback immediately. Taking time to compose yourself and consider the following is very valuable. In addition, making supervision sessions a regular occurrence is more helpful than calling the trainee in to see you every time an issue arises. How about meeting for 15 minutes per week, and having the trainee bring an interesting or challenging case of theirs, while you bring one of yours?

Content

Jack Ende’s guidelines for clinical feedback were published in 1983 and remain an excellent framework for the clinical feedback  situation. His key points are paraphrased below:

 

  • Articulate the common goals between trainer and trainee – explain why the discussion is necessary and what you both hope to get out of it.
  • Feedback should be well-timed and expected – making discussion of clinical cases habit helps to reduce the expectation that it’s a “telling-off” in disguise, and have tea/coffee – be relaxed and make sure the trainee is too. Openness is key.
  • Base feedback on first-hand data – if you weren’t there, or didn’t see the patient, don’t judge what was going on. Invite dialogue and reflection. We all know that the clinical notes are sometimes a poor reflection of the complexity of a situation.
  • Don’t overload the trainee, and stick to behaviours they can change. Try to plan in advance one aspect of the case to focus on and develop.
  • Be descriptive, non-evaluative, or better still – ask questions which invite the trainee to be reflective. Subjective statements – “that was a bit stupid, wasn’t it?” – help no-one.
  • Where subjective input is offered, make sure this is clearly identified as such; “I remember seeing a similar patient, and at the time I was concerned about… Was that something that you thought about too?”
  • Be specific. Working through cases helps; most trainees are capable of extrapolating learning points to other situations, particularly if you invite them to, but it’s important that they know exactly where the problem or praise-worthy behaviour was in this case.
  • Focus on decisions and actions, not assumed intentions or interpretations. This is the biggest challenge for me; remembering that we all see the same situation differently. Allow the trainee to recall and express what they were thinking and how they came to certain decisions. This will often expose gaps in knowledge or experience, allowing you to work together to identify ways to address them.

 

How might the above situation have been more usefully handled? In an ideal world, the trainer and trainee could have reviewed the notes and the X-ray, the trainee given opportunity to rationalise their thought process, and the possibility of alternative diagnosis raised. A wider discussion on the challenges of diagnosing non-accidental injury and the importance of its consideration could have been built on the case. Was NAI considered among differentials? There could definitely be learning points in this case, even though the trainee was not “wrong”. It is how we approach opportunities for learning and feedback which determines the receptiveness of the trainees and ultimately how behaviour can be changed.

For further tips, see the recently published “Twelve Tips for Giving Feedback Effectively in the Clinical Environment” from Medical Teacher.

 

Action

It is important that there is a clear action to come out of feedback, whether it is to do or think about something differently or to “carry on!”. I think this is most powerful coming from the trainee. Facilitate them to consider how they might approach the same case today. Are there other differentials to consider? Have they identified skills to practice? Are there phrases they could use to communicate with patients and relatives which might make confusion or confrontation less likely?

 

Say Thank You

Thank the trainee for their time; if you use feedback in this way you will not only come to understand your trainees better but you will gain greater understanding of how to help them. Although the feedback exchange exists for their benefit, it is hard not to benefit from it yourself. Thanking the trainee for their honesty promotes the importance of feedback in the relationship and builds trust and mutual respect. Two little words, big impact. Do it!

 

Self-Reflection

Every one of us is a work in progress. This stuff doesn’t come naturally and like so many skills in medicine it is worth thinking about, practising and reflecting on. Discuss with a colleague – maybe one outside the department. Invite the trainee to give YOU feedback on the conversation. Make yourself better.

 

 If All Else Fails…

Use the giraffe language: ideal for dividing fact from emotion. When you absolutely need to get something across to a trainee (for example, in the aforementioned dangerous situation), remember the language of the giraffe. Health warning: this can seriously improve your home life – do feel free to try this on your significant other.

The giraffe has the biggest heart of all land mammals, and a long neck to allow it to take an overview of a situation. It speaks from its large heart, in a non-accusatory manner, and its language is internally focussed, starting “I saw/thought/felt…”

In contrast, the snake is low to the ground, every movement around it is an attack to which it retaliates. Its language is accusatory: “You did/said/thought…”

The giraffe language is structured as below:

 

  •     Agree the facts (“I thought you were going to defibrillate the patient who was  in VF, which was the right action, but using the internal paddles rather than pads was unsafe in this patient whose chest hasn’t been opened”)
  •     Verbalise the emotions associated with the facts without outwardly expressing them (“That concerned me”)
  •     Express the need associated with the emotions (“Because I need to know that we can work together safely as a team in a cardiac arrest scenario, and that wouldn’t have been safe practice”)
  •     Agree a task to address the need (“So let’s set a time together when we can revise and practice safe defibrillation technique, and maybe go through some ALS scenarios”)

 

You can read more about the giraffe language of non-violent communication (which I have adapted a little) here.

You can also see a (theatrical) demonstration of the use of giraffe language here.

 

Happy Feedback!

 

Links

Feedback on the TTCNYC course

ERMentor on courageous collegiallity

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8 Comments

  1. Michael Moneypenny

    Thank you for this article. I particularly like the giraffe/snake concept.

    Reply
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