Teaching Prescription Pad: Observation and Feedback
Session Recorded August 26, 2021

Welcome to this session of the teaching prescription pad, where we learn the prescriptions for effective teaching from the best clinical teachers. This session is an observation and feedback. Our expert is Dr. Marci Rosenbaum. Dr. Rosenbaum is a professor of family medicine and faculty development consultant for the Office of Consultation and Research in Medical Education. Welcome, Dr. Rosenbaum.

Why is this topic important or of interest to you?

There are several reasons it is of interest to me. I think about it because in the context of clinical teaching, I feel like observation and feedback are some of the more challenging things to accomplish as a clinical teacher. Trying to accomplish those things in an effective manner can really have an impact on your learners, both in terms of their learning and being able to identify ways you can help them be the best clinicians that they can be. 

What are the benefits to direct observation?

It is hard to make time for observation, but the benefits are myriad. What I would say is, all clinical teachers’ roles are to both assess and help their learners learn all the skills necessary to be an effective practitioner. However, when you look at all the different things that someone needs to learn to be a good health care provider, several of those things are very hard to get at, just from talking to learners when they are doing presentations from their notes.

There are several aspects, especially of clinical skills, that need to be taught. For example, clinical communication in terms of how learners are interacting with patients and families is important. They could tell you after an encounter and that still would not necessarily capture it. The only way you would know is by watching. Here at the University of Iowa Hospitals & Clinics, we conducted a very interesting study in Family Medicine with Dr. Kelly Skelley, the lead author, where we video recorded encounters between residents and patients. Then we audio recorded the staffing or case presentations they subsequently made to their supervisors. What we found was, although some of the information, like the medical information would translate. What did not translate was the communication. It was fascinating to watch the video of a very chaotic interaction between a resident and a patient or patient with their child. It was completely chaotic; maybe not that effective. When they would present it to their attending, it was very organized. Everything seemed very well organized, very well thought through; it did not reflect the encounter at all. And in the same way, I think people who have effective communication skills, you would not necessarily be able to tell that from a case presentation.

Just like communication skills, physical exam skills are also fascinating in terms of benefit. I have had a couple of clinical teachers say to me, “when I finally took the time to go watch my learner’s physical exam, I realized that they were doing some of these physical exam skills incorrectly, which you would not know just from a case presentation.” Certainly, you get more insight into things like diagnostic reasoning as well. In addition, you can see how effective they are at educating patients and partnering with patients in their own care. There are so many clinical skills that make direct observation a benefit that it is necessary for helping our learners.

Since these are two topics, I am going to split them a little bit, although they are definitely connected and interspersed. How do you initiate or go about setting up an observation with the learner? What  steps or how does the learner know you are going to observe them?

What I want to emphasize first is, it does not take very much time to get something set up. It is incredibly important that you do what we call ‘prime the learner,’  getting the learner ready for you to observe them with a patient or in a patient room. The main things that you want to do with that are explain to the learner why you are observing them. In some research that we have done on observation of students, they say, well, it is hard to be observed, if I feel like it is to evaluate me, and then it is going to be part of my grade. So, I would recommend doing observation, at least partly. So, it is really just to help the learner. So in priming the learner, you would say, “I want to come watch you interact with this patient so I can get a sense of your clinical skills. My goal around this is so I can help identify your strengths and also areas for improvement.” You need to emphasize that you are not going to embarrass them or throw them under the bus, so to speak, because that is something learners are concerned about.

The other thing that some teachers find themselves doing excellently is hijacking the encounter where they kind of take over. Let the learner know what is going to happen, and how long you are going to be there observing. You do not necessarily have to stay for the entire encounter to have enough to give feedback about it. Another way to frame them, I think that is helpful is to ask them what they would like you to watch for. It is for their benefit, so they might have an idea sometimes to say, “I talk too fast, or I am not really sure how to educate a patient about this complex topic. Could you pay attention to how I am doing?” Give the learner an opportunity to say what they would want you to watch for. And then also, if there are specific things you are looking for, I tell them I am mainly looking at your counseling skills or your physical exam skills or something like that. I have probably taken more time explaining this than the amount of time it takes to get it set up for an observation.

The other thing I would say is to negotiate how this process is going to be introduced to the patient. My recommendation, especially for more senior learners, is you let them introduce you, so they still maintain the autonomy of them being the main provider for this patient. They can walk in and say, “I am resident doctor so-and-so, and this is Dr. Pettit, my supervisor. He is mainly here to observe me because I am still in training and that helps preserve their autonomy. So, I think those are the main steps to setting it up.

You have observed the learner. How does feedback fit into this combination of the two?

I would argue that you should never do observation without feedback because think about it as a learner. If you have come in the room to watch them and then you do not say anything afterwards, they are going to think one of two things. They are either going to think, “well, I must just be awesome and don't need to work on anything,” or they will think “it was so bad that they will not even talk to you about it.” What we want is for learners to not be guessing what you observed and what insight you have, but for you to tell them. With feedback, it is important to prime learners. Then during the observation, I would recommend that you take notes so you know what you are watching for and you can remember exactly what you saw them do. Afterwards, feedback is key. So the third step is the only reason to observe is to gather data on which you can then give the learner direct feedback.

I agree with you as far as taking notes, because my memory would not last very long. Does just taking notes kind of put a little stress or pressure on the learner. Do they see when you sit down, start writing something, they get upset about it?

I do not think overall. I think that is a good point. That is part of what you could include in your priming. To the learner you can say, “I am just going to take notes on the things that I noticed so I can give you really effective feedback.” Maybe they will not be as intimidated, especially if you are saying it is not part of your grades. If you are sitting there filling out a checklist, I think that would be intimidating to anyone. There might be times that you need to do that. I think here we are talking about how you can use observation as an educational tool and how I can use feedback as an educational tool. It is not about assessing, grading kinds of things.

What are some effective ways to give or provide feedback to the learner?

There is so much written about this in the medical education literature and there are so many different recommendations that I think what I would like to do is put it in simple terms. There are many models for this one that I particularly like because it is easy to remember. It is called the Ask, Tell, Ask model. What that emphasizes is you start any feedback conversation. I do want to emphasize conversation because it should be an interactive conversation. You start by asking the learner their perspective on what you have just observed. Ask them “how do you think it went?” or “were there parts that felt tricky?” or “is there anything in particular that you would like feedback about?” What that does is it gives the learner the opportunity to say this is what is most salient in my mind. So even though you may have a lot of things you want to tell them, they might be worried about a particular word they use or something that happened later in the encounter. If they are really worried about that, it might be hard for them to hear everything else you want to tell them.

I think it is always worth asking the learner to do what we call ‘self-assess’ or give them an opportunity to guide the conversation. That is the ask, step one. In terms of giving feedback, I think with the telling, some of the main principles that are helpful are what feedback is really. I love this definition: the art of observation and description. The feedback part is just describing what you saw. “I noticed when the patient was talking about X that you interrupted her and actually asked more about Y and I was not sure how the patient felt about that.” Saying something very specific about what you are noticing and being able to describe it helps. Talking in general terms, saying it was good or it seemed like you did not care about the patient or whatever it is you want to say generally is not helpful. All I can do is change their behavior. They cannot change the inference. So, describe a specific behavior. That is why notes help, because you can say, “I heard you say this, which was a really effective way to get the patient to feel comfortable.”

It is a balancing act between talking about what the learner did effectively and what could be improved. You can probably think of teachers you have had who were really good at telling you what you did not do well, but not so good at telling you what you did effectively. A lot of us find it hard to tell people what they need to improve on. We may be really good at telling them what they are doing effectively. So, you really need to balance both—reinforce what is working and make suggestions for improvement. That is your role as a teacher. 

The third thing I would emphasize is in addition to that balance, to not give too much feedback because you can overwhelm the learner. Pick one or two points because we know with learners, if you start talking about lots of things, even if it is everything they did effectively, they are not going to walk away remembering those things. So, limit the amount of feedback you are giving and then go back to the ask, tell, ask model. You ask, you tell them what are the things that you notice being behaviorally specific and then you finish by asking them how does that sound or how will this influence their future practice? Specific, balancing those things, and not talking too much. When they have similar situations like that, it kind of closes the loop and lets the learner again take responsibility for incorporating the feedback you give.

What are some reasons that clinical faculty would push back or say, I cannot do observation, or I cannot add the feedback? What are the challenges that they might encounter and how would you overcome some of those?

Well, the number one challenge that I hear, and I do a lot of teaching of clinical teachers, is time.  I think this is the number one challenge in all our work. One of the things I really like to emphasize with this observation and feedback is making time for it does not take that long. In terms of observation, a lot of people say I do not have time to go watch the whole encounter. As I already mentioned, you do not have to watch the whole encounter. I would suggest you do it pretty early when they start working with you, so you have a baseline. You can see how they grow over time with you. You could do it first patient of the morning. Before you get really caught up in your own patients, you could go and watch the learner take a history for the first three to five minutes. That will be enough to be able to give them some feedback. Another opportunity is if you have learners who staff with you after they round in an inpatient or  outpatient setting. They come and they make the case presentation. Often what happens there is after they do that and talk to you, the next step is for them to go back and tell the patient what they think is going on. That is a great opportunity for observation to say I am just going to come in with you and watch you share information with this patient or this family. 

We spend a lot of time teaching about history taking. We do not spend as much time as we could teaching about how to effectively educate patients. So that is a great opportunity and could just be done in a few minutes. With observation, I think that managing time is just going, “oh, you do not have to watch the whole thing.” There is data that shows watching a learner for several short observations tells you a lot more than just watching one long in terms of feedback and saving time. I think it is what I already mentioned, which is it does not have to be a very long conversation. And in fact, if it is a long conversation, you are probably overwhelming the learner and you are decreasing the educational value. Just knowing you do not have to say that much and letting the learner kind of lead can still help. Time is one big obstacle.

I think the other big obstacle is worried about making the learner uncomfortable. All the things we have already talked about in terms of why priming and getting the learner ready is so important, because the biggest thing you are doing there is you are saying this is for your benefit and I am creating a safe environment to do it. This is not to punish you or to grade you. This is really to help you. In the same way, as far as feedback goes, I think a lot of people are worried about giving what we call ‘constructive’ feedback or telling a learner how they can improve. They are learners. What we hear from learners is that it is what they want to know. They want to know how they can be a better clinician than they currently are. To hear it from a more experienced clinician is helpful as long as it is based on specific behavior and they are given some opportunity to identify how they can change and what will help. I think that addresses the main obstacles I see or hear about.

It is my experience that a lot of faculty, once they provide the feedback, assume that the students are going to go fix it, whatever it is. How can I, as a teacher, reinforce behavior or make sure that they listen to what I suggested and keep going forward?

There are a few things about making sure that they listen. That is why we do the first ask, because we want to make sure the learner hears what you are saying. If you can tie it to what they are worried about or they care about, the more likely they hear it. The second ask about can be used even if part of it is kind of like what we do in patient care, which is getting the patients to do teach back and say, here is my understanding of where we are going from here. You can ask the learner to make a commitment to something you are going to do next time. I think the other big part of it is you must follow up and you have to notice if they make the change or if they do not. Our learners are very efficient, and they know if you ask them to do something, but you never follow up, that they do not really need to listen to you. Use the next day or the next patient they see for observing them again. Were they able to incorporate this change or asking them explicitly. Sometimes people will notice that their feedback was not taken on and then it is important to give the learner feedback and say, “you know how we talked about how you need to include this in your notes or your presentation or your interaction with patients, I noticed you still using lots of jargon with the patient. What can I clarify for you about that feedback I gave you before?”

Are there any other areas or words of wisdom that you would like to share with educators going forward?

I think the biggest message I am trying to put across here is you can do it and it is so helpful to learners and eventually helpful to you. If you have learners in more challenging encounters with patients, observation is often the biggest tool that helps. If you have a learner who is not very time efficient, the best way you are going to figure out what is going on with them is to watch them. If you have a learners with other challenges, I often think the observation will help. In the long run, that saves you time, even in the most difficult situations. I guess the other big message is it is not as big of a deal as it feels like to do and with practice. If you just make both of these things part of your routine, observation and giving feedback on a regular basis, it will not seem like the special occasion where your learners really screw up. That is why you are doing this. I think making this part of the routine is probably the one big message to end with.

Thank you very much for your time and information.

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The video transcript and podcast will be available on OCRME’s website in the future (https://medicine.uiowa.edu/ocrme/teaching-development/teaching-prescription-pad)