Thread by @gabmayer

Hello #medtwitter!

I recently gave a talk on "feedback" to my primary care family -- er, colleagues -- at @nyulangone/@BellevueHosp.

I learned SO MUCH and think some #meded tweetorial content (🧵) is in order.

1/25

First and foremost: why does feedback matter?

For that, I'll turn to the theory of deliberative practice (ToDP).

(Which, for a TL;DR, is a great framework that helps us become experts at whatever skills we choose. Similar to M. Gladwell's 10K hours, but much cooler).

2/25

ToDP says:

❗️ Feedback - nor any skill - is something that comes from "natural talent", but rather something we carefully cultivate over time

❗️Being adept with feedback helps us become better at other skills.

(Check out images for quotes from the OG article).

3/25

Within the context of clinical medicine in PARTIC, feedback is essential - it serves as a “mirror” that allows us to reflect on the complex cognitive, psychomotor and affectual art that is patient care.

(Paraphrasing Jack Ende's '83 JAMA article - bit.ly/EndeJAMA)

4/25

Ok, let's get into talking about KINDS of feedback.

You can slice this any which way - written vs. oral, informal vs. formal, "positive" vs. "constructive", summative vs. formative.

(Feel free to comment with ones I missed below!)

5/25

My favorite model for feedback is pulled from Thanks for the Feedback - book by D. Stone and @SheilHeen.

It involves a three-pronged approach: appreciation, coaching and evaluation.

Image has all the deets, using an example to explain the difference between the 3.

6/25

Ultimately, how we classify feedback is less important. What IS important is making sure we give a DIVERSE array of feedback.

What do I mean? Join me on a thought exercise.

Via a stroke of luck (or some witchcraft 🧙‍♀️), you're now an intern on a medicine service.

7/25

For the WHOLE month, you get appreciative feedback but NO coaching. End of the block comes with evaluative feedback on what you could've done better.

A natural response: "🤬! Why didn't I get this constructive feedback earlier?

8/25

Now imagine you're an intern still and on ANOTHER wards block.

For THIS month, you get ALL coaching with a sprinkle of evaluation at the end. But NO appreciation.

End of the moth rolls around, and this is how I'd be feeling: "☹️🥺. Why am I such a TERRIBLE doctor?!"

9/25

The big takeaway here:

❗️Learners benefit most (and respond best) when they experience a full FEEDBACK ECOSYSTEM - various forms of feedback from the SAME source.

10/25

Ok. And now the harder question. What makes for GOOD feedback?

Let's 🛑. What is "GOOD" feedback anyway? Is it positive?

Maybe we can rephrase this as "IMPACTFUL" or "TRANSFORMATIONAL" feedback - whether positive or negative. Cause that's our ultimate goal, ain't it?

11/25

How we assess impact is a whole bag o' worms. We can use a #meded favorite, which is the Kirkpatrick model.

It asks, “Did the feedback resonate with learners? Did it change behaviors or learning? Did it change patient outcomes?”

12/25

Let's start with the bottom of the Kirkpatrick pyramid - what kinds of feedback resonate (positively) with medical trainees?

Five big themes arise:
❗️TIMELY
❗️BALANCED
❗️SPECIFIC/CREDIBLE,
❗️SAFE
❗️ACTIONABLE

13/25

First up: keep the feedback coming!

- Trainees value regular, consistent and unprompted feedback (bit.ly/KMAcMed)

- Be wary of quantity w/o quality; provides limited value as hard to couple meaningful observation to the feedback (bit.ly/LDayAcMed)

14/25

Per evidence, trainees want a FULL FEEDBACK ECOSYSTEM.

- Appreciative feedback ↦ safer learning env (bit.ly/BingYou)
- But ALSO constructive feedback in equal measure. To quote a resident from this study (bit.ly/KMAcMed), “not overly cushy”!

15/25

SPECIFIC & CREDIBLE feedback comes up a lot. This means:

- Based in CONCRETE OBSERVATION
- Has a CONTEXTUALIZED understanding of the receiver's role on the healthcare team (bit.ly/Eva2012)
- Aligned w/ a trainee’s own edu. goals/values (bit.ly/watling12)

16/25

Unsurprisingly, trainees want PSYCHOLOGICALLY SAFE feedback:

- Interactive & learner-initiated
- Bi-directional
- Clear unspoken intent: learning and growth
- Free of fear: of retaliation, consequences, shame

Sources:
bit.ly/watling12
bit.ly/BingYou

17/25

Lastly, trainees value ACTIONABLE feedback where the homework is clear.

- Action-oriented
- Accompanied by concrete suggestions for change, or obvious next steps

Sources are sundry, but here's my fave: bit.ly/BingYou

18/25

PHEWPH! That's a lot of great suggestions for feedback.

But coming back to the Kirkpatrick pyramid - we've only tackled the bottom rung.

What about the rest? What feedback that moves the needle on learner performance and learning - or even on patient outcomes?

19/25

Not a ton of evidence on this. 2 big studies - a Cochrane review (bit.ly/CochrFB) & a syst. review (bit.ly/SystRev)

Their findings reinforce feedback that is:
- Timely & regular
- Comes from credible sources
- Comes with follow-up/next steps

20/25

Most interesting of all, these studies suggest that transformative feedback has a LONGITUDINAL dimension.

The most impactful feedback included:
- Repetition over time
- An arc continuity with the same evaluator - on the order of months to years.

21/25

FWIW - this longitudinal dimension is hard to accomplish within an academic medicine environment because we:
- Rotate teams constantly
- Prioritize patient care (sometimes at expensive of team bonding/relationship building)

22/25

To that end, some have suggested we reinforce the mental model of an "educational alliance" between learners and evaluators (similar to the concept of a"therapeutic alliance" between patients and providers).

23/25

Okay! That's a lot. Let's do some summarizing.

🗝 Proficiency in feedback is important because it goes hand-in-hand with developing expertise (in ANY skill, esp doctoring)

🗝 Feedback is really an ecosystem - we want to give and receive many DIVERSE varieties.

24/25

🗝 Rather than viewing feedback as "good" (+) or "bad" (-), I propose a reframe to grade our feedback as "impactful/transformational" versus not.

🗝 Per the evidence, the most impactful feedback is: timely, balanced, specific & credible, psychologically safe, actionable.

25/25

Tagging some who might find this interesting, some who helped this talk evolve. (Pts 2/3 coming soon!)
@MackLipkin @SandyZabarMD @AGoodwinMD @janjim01 @CchristmColleen @richardgreenemd @anirudhkumar01 @meggerber @InduPartha @HannahRAbrams @aoglasser @jessicahalem @DrPoorman

@BenjaminSolder @YihanYangMD @nancyskehan @NoodlePremed @michaelturk6 @markhoffmanmd @malstummd @DrNRedmond @paineducatorMD @sweetchinchilla @DavidPJohnsonQI @Robertu74498427 @KimberlyKho1 @RakheeBhayaniMD @BrittGratreak @melina_manolas @SteveBrownMD

@PaulNWilliamz @ChristleNwora @mmteacherdoc @GIMaPreceptor @RZChipMD @SamuelMaidman