Feedback Success (4 April 2024)

SPEAKER_01 0:14

Hello and welcome to Consultative Conversations, a podcast series developed to support early career consultants, brought to you by the recently appointed Consultants Committee at the Royal College of Physicians of Edinburgh. My name is Helen Liddycote. I am co-chair of the Recently Appointed Consultants Committee and a respiratory consultant working at NHS Tayside. Today I will be discussing feedback success with my colleague Dr. Lynn Ergott, who is an infectious diseases and general medical consultant at NHS Tayside, an assessment and feedback lead for the University of Dundee Medical School. So, Lynn, I know you've completed a PhD exploring what makes feedback successful. I can't think of a better person to enlighten us on this subject today. Oh, thanks so much for having me today, Helen.

SPEAKER_00 1:01

So we'll start off with why is feedback important? So feedback when it's successful is really important because there are lots and lots of meta-analyses from the psychology literature that tell us it's one of the top influences on success and on achievement. But the challenge with feedback is there are also quite significant numbers of papers that tell us that feedback can actually be detrimental to learning if we get it wrong. So I think it's important that we understand what it is that makes feedback successful rather than just feedback in of itself.

SPEAKER_01 1:37

I think giving feedback is one of the most joyous parts of my job, kind of giving back to trainees and students and helping them then develop is you know one of the things that makes your job worthwhile, isn't it? But getting it right is often much more complicated than we think.

SPEAKER_00 1:52

One of the challenges around feedback is even that concept of the term giving feedback, because in your mind that kind of helps you associate it with being a really one-directional thing. You know, the feedback provider gives some information to the learner without really much opportunity for discussion and like co-creation of feedback. And there are some people that use feed forward rather than feedback. So how is this information going to help them to improve in the future? And probably feedback kind of encompasses all those things, looking back, taking stock of where you are now and looking forward in order for it to be successful.

SPEAKER_01 2:29

Yeah, we have a bit of a problem with labeled there, don't we? Because we do use that term and it should be much more of an interaction.

SPEAKER_00 2:35

Yeah, definitely. We have to think of feedback as communication, essentially, okay. And when you offer information, which is intended to be feedback, the problem is that that information doesn't stay in the form that you have offered it. It undergoes change in the learner or the recipient and it goes through all these filters, and it's only once it's traveled through all of these filters will that learner then decide whether they're going to utilize that information to help them learn. So I think the challenge with improving feedback is that being in the past, all of our feedback interventions have been aimed at the feedback provider. So here's a tool you can use to provide feedback, whether that's the feedback sandwich or whether that's, you know, a little bit of paper that might tell you how to do it, whether that's an e-portfolio, etc. But the problem with focusing only on the feedback provider is it doesn't take into account any of these filters and it doesn't take into account the learner. And so it will not improve feedback unless you do that. So are we any good at giving feedback? I think we're mixed back, really. I think sometimes we are and sometimes we aren't. And it's not even to say that one individual person is always good at it, and another person is always bad at it, because feedback is really contextual. And I think that's the thing you really have to understand is all of the contextual factors around the feedback that are going to determine whether it's going to be useful or not. And I wonder if to give you some insight into that context, now's a good time just to explore those filters to explain what I mean by those feedback filters. Basically, when you offer feedback to somebody, it goes through the filters at the individual level, the social level, and the cultural level. Okay. And so you have to kind of understand what each of those filters are and how they might impact on the dynamic between you and that learner and whether the feedback's going to be successful. So individual levels are things like the self-esteem of the learner. Now, there's not very much you can do about that, but that is definitely a factor. The emotional state of the learner of the trainee, the feedback legacy of that person. So, what has their experience been of feedback in the past? Has feedback been helpful for them? Have they actually found feedback to be a helpful thing for them? Or has feedback been a really poor experience for them in the past? And therefore, they're bringing all of that legacy with them into this interaction you have with them. And there's also individual in terms of the feedback provider as well. So the emotional state of the feedback provider at that point in time, the feedback legacy of the feedback provider. So, does the feedback provider actually find feedback to be useful? Or has their experience always been, oh, feedback for me was never useful, therefore I don't think it will be useful for me to provide it? So there's all this kind of legacy, emotional esteem factors involved at the level of the individuals. And then there's filters at the level of the social. And what that really means is the relationship between the feedback provider and the feedback recipient. So what is the nature of the relationship? Have they met before? Is this a one-off interaction? And it's not to say that one-off interactions are a bad thing necessarily, but you have to recognise that what you're able to achieve with a one-off interaction on a wardround will not be the same as in a long-term trustful relationship with a mentor. So it's just recognising, okay, what is the relationship that I have with this person? What have I done to kind of make them feel that I'm on their side, that what I'm here to do is to help them develop rather than to kind of be tokenistic or whatever. And also one of the big factors that comes in at social is the credibility factor, which is my favorite factor around feedback, which I think we can all probably resonate with, which is that basically if you don't think the person providing you feedback is credible in your eyes, then you will discount the feedback they're providing. And so that's really fascinating to me, because I think we can all think about consultants, for example, that we maybe had when we were trainees. The ones that we really valued the feedback from were the people that we thought were good doctors. So not necessarily the best educators, not necessarily the people who've been on lots of staff development courses in terms of feedback. And maybe they do it in a way that if you were filming them, you might think, oh God, that was an atrocious way to provide feedback. But that feedback matters to the trainee. And if it matters to you because they're credible and because you value them as a doctor, you're way more likely to utilize that feedback for change. So we've got individual, we've got social filters, so like the relationship, the trust, the credibility factors. And then we've also got cultural factors, and culture isn't just geographical culture, but there is a factor of that of, you know, trainees depending on if they've trained elsewhere in the world or even elsewhere in the UK, or even elsewhere in the same trust, but there's a different culture, then their cultural expectation is going to be potentially different. But there's also an institutional culture aspect as well of how does the institution role model responds to feedback from the trainees, right? So if the institution asks for feedback from the trainees and the trainees are saying, This is poor for me, this is great for me, this makes my training really intolerable, but the institution ignores that, doesn't do anything with that feedback, doesn't even reflect that they've listened and that they understand. The trainees gonna think, well, it's double standards. They don't care about me, so I don't care about their feedback. So there's all of these filters, and this is before you've even got to the content of the feedback. And here is why interventions that only focus on content of feedback will fail. They're not gonna make successful feedback. What you actually have to understand is all these contextual factors makes it really hard, then, doesn't it? To make feedback perfect. But a starting position at least is to understand the influence of all these things.

SPEAKER_01 8:48

Yeah, it's really thought-provoking that actually we need to be much more mindful about those filters, but also heartening that actually just by being a good doctor and delivering the best care to our patients, that's setting a really good example to our students and trainees, but also allowing those interactions to take place in a sort of meaningful and authentic way.

SPEAKER_00 9:09

And role modelling can't be underestimated. You know, I think it's what you are like as a good doctor, but some of that is how do you role model when you've had negative feedback? So for example, if you have a complaint or something, because we all feel terrible if we get a complaint, it does feel horrible. Can you share with your trainees, particularly if they're senior trainees and they're going to be having to answer their own complaints at some point, oh, this came in, it made me feel like this. I sat on it for a couple of days because I knew that my emotional state in that moment was not the time to write the response to feedback. So here's how I dealt with it later. I spoke to a senior colleague who'd been through this before and we talked it over, you know. So just role modeling response, bringing your sense of humanness to the interaction and saying to the trainee, I see you as a human. I am also a human. Here's how two humans are going to help you do the best job you can do. I don't think I mentioned earlier, but I think it is important that we note that obviously it's important that we provide feedback for our trainees to help them have the best experience and to help them be the best doctors they can be, but also for patient safety, right? That is ultimately why we're here. We're here as consultants to make sure our patients are safe and have a good experience. Even if we don't want to have to provide developmental, negative, critical feedback, however you might phrase that, we have to. Because we have to be certain that we're doing a good job for patients.

SPEAKER_01 10:36

Yeah, it's a really important part of our clinical governance, isn't it? Reflecting on all these filters, I think our loss of team structure and the fact that when we're interacting with students and trainees, we don't necessarily know them very well and we don't necessarily know their history. How do we combat that? So, what are your top tips of giving effective feedback, both in sort of dedicated teaching sessions where you might know the trainees a bit better and you might have a bit more time, but also while you're doing the day job when you're on a busy ward round and you've got lots of competing demands and sectioning off the time to do this in an effective manner?

SPEAKER_00 11:10

So I think the first thing is recognising that you aren't going to be able to do the same thing on a busy world round as you might as in a dedicated educational supervisor meeting. And that is fine because what you need is a mixture of both kinds of feedback. So if, for example, you're saying on a busy take and I'm going to provide feedback on something for a trainee that I've maybe met once or twice and they're not my specialty. So I don't have a recurring necessarily relationship with that person. What's important, I think, is that you set clear expectations because in life, this is one of my top tips for my PhD. It's one of the things that sat with me most, which is satisfaction is directly linked to expectation meeting. Okay. And so where you were dissatisfied is when you have an expectation gap. One of the easiest things you can do is just set clear expectations for the offer. So for example, as an educational supervisor, it may well be that the supervisor your trainee had before you met with that trainee every Tuesday for two hours, bought them lunch, and they had a good mentoring chat. And it might be that you just don't have that as a realistic thing that you can offer. So instead, saying to them, okay, this is what I intend on doing for you and with you over the next four months or the next year, however long you have that trainee, we're going to meet on a monthly basis on a Tuesday for a half an hour, and we're going to talk about the following things. The week beforehand, can you email me anything you want to talk about? Setting really clear expectations. So that would be in your kind of educational supervisor role. But on a kind of day-to-day teaching session, it's just expectation of saying, I can't give you feedback on every single aspect of take, right? Because that's massive. Instead, what would be better is I give you quality feedback on one aspect of take. And so what you might decide, and you might not want to share beforehand what the thing is that you're going to look at, but I would probably say decide in yourself as the consultant, okay. Today I'm going to watch how that person leads the juniors. Or today I'm going to watch what their decision-making skills are like, particularly with regards to discharge. Or today I'm going to watch how they interact with the nursing team. And you might pick that based on previous feedback they've had, or they might ask you, could you give me feedback on this? There's various ways you might decide that. And I think it's important to pick one or two things and to give really good feedback on that. And the reason is I think we've all probably seen that video where you're asked to count the number of times a team throw a basketball and you're so focused on watching that team throw the basketball that you don't notice the big gorilla that walks across the front of the screen until someone points it out to you. And I think that's important, the same thing with feedback in a busy environment, is when you're so busy looking at the whole thing, you actually don't look at it properly. And actually, what you should be doing is going, what I'm going to look at is one thing really well, and I'm going to try and work out how I can help that trainee, not how I can criticize or what I can find that they're lacking in, how I can help them be the best that they can be at that thing. And then you might say to them, okay, say I was looking at your tech management, and then you have to then explain what you're basing your judgment on. So I would probably say, Okay, so you're an SC3. Normally I would expect an SC3 to do the following things. And I think you either met that standard or you did that, but you also did this, which was excellent, and I think you know, was probably more at an SD4, SD5 level, or you actually didn't manage to do these things, specific skills that you'll need to work on for later. And so just being really clear so that they understand what are you basing your judgment on, and then some specific tips on how they can get to the next bit.

SPEAKER_01 15:06

I love that. So focusing your attention on bite-sized channels, but also you're sort of doing a lot of signposting that you are giving feedback and you're kind of engaging in that dialogue and sort of showing them what the expectations were and setting what they're doing against that, as well as supporting them developmentally. It's great.

SPEAKER_00 15:24

And also helping them to do it in their way that's authentic for them. So not saying to them, here's how I do it, but basically saying, Here's examples of a way you might do it, but you have to find the right way for you because everyone doctors in a different way. That's the thing, isn't it? We all find our own way of being a doctor. We're not here to act as someone else. We're here to find our authentic self in being a consultant or in being a registrar or whatever. And so you might provide a couple of examples, but ultimately helping them find their authentic way of doing that thing. In a safe way, obviously, too.

SPEAKER_01 15:57

I think that's really important. Lots of people will say, you know, this is the way that I do it, and not be open to the fact that there are multiple ways. And that can often be confusing, can't it, to trainees and students when they see people do things differently and they want to know the right way of doing it. And there isn't the right way of doing things at all.

SPEAKER_00 16:12

Absolutely. Like there's maybe certain goals that you have to meet, but the way you meet those goals will be different. I think it's really important as feedback providers to try and recognise that individuality in our trainees. That can be quite hard. But what we're not trying to say is I'm going to give you feedback on what you're like compared to me. What you're doing is giving them feedback on helping them be the best version of them.

SPEAKER_01 16:38

Absolutely. And when we don't know the trainees as well as we'd like to and their background, why do you think that's important, first of all, to know where they've come from? And also how can we mitigate against that in our modern day structures of working to make sure that we do give the best feedback to trainees?

SPEAKER_00 16:55

Yeah, I think it is really difficult. You can just ask them the first time you meet them, you know, particularly if it's an educational supervisor type thing, you know, how did your last block go? What was your feedback like? How did you feel about that feedback? And most of them will have an e-portfolio of sorts that you can have a look at their last e-portfolio educational supervisor form just to understand if there are certain things that have come up. And if there are, it's probably not a bad thing just to get that out in the open to say, so I see that this was something that you struggled with or that was raised before. Do you agree with that? Because if they disagree with that feedback, they're never going to try and move on from that. Okay. So tell me more about that. Did you agree with that? How can I help you in that specific thing? In terms of like just meeting someone on a one-off, I think it's quite hard to judge how that person has progressed. And all you can really do is judge how you think they're getting on with respect to their peers. If it's an occasional interaction, that's all you can do. But I think if you have a regular interaction, the better thing is to judge them how they're getting on with respect to themselves. And that's where those two types of interactions are important. You need both. You need to understand where they fit in the bigger pool, but you need to understand also where they fit on their own learning journey too. Yeah.

SPEAKER_01 18:13

I know that your team and the Resbruch team as well meet and discuss how the trainees are doing. We don't do it so much for medical students, maybe we should to talk about how they're doing over a longitudinal period of time. So we do get to know them better in different scenarios. Because you might have a snapshot of a medical student or a trainee in one environment, and it's quite hard to pull all of that together.

SPEAKER_00 18:35

Yeah, definitely. We have a monthly consultant meeting where we discuss all sorts of governance stuff, but one of the standing items on that is trainees. And we also do medical students on that actually, because we have final years who spend eight weeks with us, so they're with us for quite a long time. We just talk about how they're getting on, basically. Are there any challenges? What does everyone's general feel for their progress look like? Because we run like a consultant of the week system, so I might be on the week, the trainee starts, I might not be back for another six weeks, and I may have missed the vast majority of the time that they are there. So I think there's all sorts of ways you can find out information, whether that's speaking to colleagues, whether that's looking at their ePortfolio, particularly if there is a trainee who has struggled with various assets in the past. I know that the foundation program people will sometimes email you ahead of time to say just to give you a heads up, this trainee's coming to you, they've had some challenges in their last block, here's what we're working on. So I've certainly had that situation, which can be really helpful because you know what to expect from that person. But I think it's also important to recognise progress so that trainees don't become disheartened because we all have different trajectories, and some people will just be amazing from day one, never have any dramas. They know how to reflect, they know how to learn, they know what they need to do, and they just are so good. Others struggle with that, either because they're not amazing at self-reflection or being like self-directed learners, or because they've got challenges going on at home or in their life or with their health or that kind of stuff. And so it's not fair to compare those two trainees, to compare the trainee with no difficulties who's amazing with the trainee who has lots of bumps in the road. And it's really important for the trainee with lots of bumps in the road that you're helping them compare their progress with themselves. Of course, you have to check that they're performing at the level you would expect for their peers, because ultimately there is a minimum standard to progress to the next level, but that they don't get disheartened, that you're not saying, oh God, you're never as good as Joe or Joanne, you know. Instead, you really struggled with this and you've made really good progress on this thing. We're not quite there, but you have already made really great progress. Let's keep going. So you're still providing feedback for those trainees.

SPEAKER_01 20:48

That's really helpful. What are the other challenges of giving feedback in your experience? We've talked about a few there, the structure of how we're working.

SPEAKER_00 20:57

Yeah, so I think certainly relationships, because relationships are key and the emotional state of the learner is really important. And I know that others have worries really when they're the feedback provider that there might even be some comeback on them or some like fear of reprisal if they provide negative feedback to a trainee or that kind of thing. So I think the most important thing is remembering at our core we have patient safety as our number one priority. Obviously, we have trainee well-being and support and development as very close to that. But at our core, as consultants, patient safety is there, and we have to remember that. I think if you have concerns that you're going to have a particularly challenging interaction, nobody wants to feel hijacked, for example. If someone feels hijacked, they might be more likely to have quite a strong emotional response towards you. So I think it can be quite helpful, particularly if there's something quite serious that you need to discuss with someone. somebody that you give them a heads up about the specific things that you want to discuss ahead of time. That means that that emotional immediate response to being challenged when that thing happens away from you. That gives them a chance to kind of bed in with those feelings a little bit and think it over and think about what they want to discuss. And then make an appointment to speak with them after they've had a few days for those things to sit with them. And then it may be that you want to meet with another person too in a similar way to us meeting with challenging you know patients or challenging you know relatives or whatever. We're generally quite good at judging if that situation is going to be safe or unsafe for everyone involved. And I think if there is concerns you could do it either I mean in an ideal scenario you're doing face-to-face feedback in this kind of situation. The challenge with face-to-face feedback is if you feel unsafe in that particular situation as the feedback provider. And so if that's the case, you might want to have a group of people you can offer that that person brings someone with them. But I certainly think providing them with information ahead of the meeting of here's why I feel like we should meet, here are the things I want to talk about is a really top tip for allowing that initial immediate negative emotional response to happen away from you for them to have a chance to reflect on that.

SPEAKER_01 23:22

We've talked before about your emotional response as the feedback provider as well and how that can interact. So if you're giving feedback in a very kind of challenging situation where you might have the patient to look after as well giving feedback in that moment is not the right time because of your own emotions as well and checking in with yourself and how you're feeling and how important that is.

SPEAKER_00 23:45

Absolutely I think you know particularly for example in like an emergency situation or something like that where you feel quite seriously that something has gone wrong in the way that a trainee has maybe interacted with a patient or whatever has happened, that is not the time for you to discuss the ins and outs of that particular instant because you are feeling whether you're feeling annoyed scared tired hungry you haven't had a P for like 10 hours on the take or whatever you are not in a good place to be fair in that feedback interaction and you have to just recognize that. And they won't be either so that whole thing will be a disaster. It is fine to say I need to step away from this situation please I'm gonna take over or I'm gonna ask someone else to take over looking after this patient. Can you go and get yourself a cup of tea I think you need to eat something I think you need to get a drink come back in 20 minutes. But we do need to talk about the specific thing I've got time on Tuesday are you in on Tuesday? Come and speak with me so it's basically removing them from that scenario because they're probably now in a situation where they're not making good decisions for their patient either. Not making good decisions for themselves they're not making good decisions for their patient if something has gone wrong that isn't the right time and so it's just removing them from that scenario I'm a feeder so generally advising people to eat something I feel like is always like go eat go have some biscuits get some food but recognizing exactly like you said if you're feeling annoyed with that trainee or you're just feeling tired you're exhausted after a take that is just not the time to have developmental critical challenging feedback. That is just not the time.

SPEAKER_01 25:28

Learning when not to give feedback is a really good skill I think stopping yourself and doing it in that much more measured way and thinking about longer term outcomes rather than just your immediate want to resolve that situation.

SPEAKER_00 25:42

And I think recognising in ourself that we're all human that it is also okay that if you do in that moment say something that you know you reflect on as you're driving home, oh God, I probably didn't handle that that way to role model in that and to email and say listen that didn't go very well I'm really sorry for the way I spoke. I was worried about the patient I was tired and I shouldn't have spoken to you in the way that I did having said that we do need to talk about this when we're both have had some sleep and had some food and things are a bit camera so come and see me next week and we'll talk about it. So I think all of that role modeling because you're showing you a reflective person there that you're reflecting that you weren't in the right space that you maybe did something in a way that you now regret that's okay. Like bringing the human in there can only be a good thing.

SPEAKER_01 26:29

Yeah. Always good to acknowledge that emotion and be a kind of thing. I think the educational supervisors I found really helpful in the past if there is an interaction that I feel was a bit unusual then kind of getting the educational supervisor on board and finding out a bit more about the trainee and getting their support is often really helpful as a provider if you're worried about giving feedback.

SPEAKER_00 26:49

Definitely but I think as well like I don't want this to feel really negative either. I am aware we're talking about the challenges around feedback but like you said right at the beginning it feels so good to be able to provide positive feedback. In fact sometimes I use that as an approach if I'm having a particularly bad day one of the ways I can make my own day better is if I email someone and tell them they've done a good job because you know that that has made that person's day better and by proxy that makes your day better, right? I referred quite a complex patient to my colleagues in neurology and I've just come back from a couple of days off and there's a letter from the neurology registrar which is amazing a really really brilliant letter really thoughtful really in-depth really helpful and so I've just emailed them yesterday and said I loved your letter so informative please will you let me know what happens with this patient. Maybe all his letters are like that and no one tells him his letters are amazing. But that's a trait I don't know very well I was struck by God what great great thinking and compassion and plan in the letter of that person. I'm going to email them and tell them that top tip if you are feeling a bit burnt out I feel like a salve for your own burnout is to help someone else have a better day. It really honestly really helps me if I'm having a tricky day or say I was on a terrible take for example and it was really really busy and I just was like oh that was really hard but the registrar was amazing. I will email them and be like God that was a hard day but you did such a great job I couldn't have done it without you they'll probably be feeling really broken potentially in that situation too. So I would sort of implore as a way to help our trainees but honestly it helps you too as a salve for your own tiredness or whatever. Make someone else's day better and it will really help.

SPEAKER_01 28:40

Makes you feel so good to be able to give positive feedback and it generates more positivity.

SPEAKER_00 28:48

Sort of every day say okay right what five positive feedback things have I given to people whenever I email a trainee who talked about contacting educational supervisors with links haven't gone wrong but I also always do it if I'm doing positive feedback so I will always copy in their educational supervisor or the clinical lead of that department or whatever just as a little by the way did you know that this person's really good because I think it helps the trainee to feel that other people see them because it's really hard. Training is long right and it's hard. Medical students doctor trainees are for the most part amazingly hardworking people and the system is hard just now and so I think what we need is even more encouragement.

SPEAKER_01 29:52

It can be yeah immensely rewarding kind of watching people on that journey.

SPEAKER_00 29:57

And that comes down to two things that comes down to trust and relationship between you and that person so that you maintain that good relationship with that person so that they see that that feedback helped them. And what that does is that then flips our feedback legacy so that feedback now becomes a helpful strategy for them not a detrimental strategy. And that helps with this growth mindset. If anyone's got kids at primary school they are all aware of all the tattering growth mindset but growth mindset is really important which is recognizing that basically we're not good at something or bad at something that all of us have the ability to develop in everything. And so trust, relationships, culture, emotions all of these things are going to be the things that really help somebody to develop as a doctor because you're not training a trainee. This is like your peer the your future peer in three, four years this is the person you're gonna share an office with and what have you done to develop that relationship with that person? What have you done to develop the trust the relationship the skill set of that person and in four years time when they're sharing an office with you obviously not everyone stays but if they are have you been a helpful supportive colleague to them that's so fascinating.

SPEAKER_01 31:13

Thank you so much Lynn there's been so much there to think about and contemplate and I think I'm gonna be so much more mindful in the way that I deliver feedback in the future so thank you very very much.

SPEAKER_00 31:25

Oh no problem I always love talking about feedback so entrenched in everything we do in our jobs but in life in general lots of this can be attributed to lots of the things that we do the way we look after our patients the way we are in friendships the way we are with our kids and so thinking about the context and thinking about the emotions and thinking about the trust and relationship in all of these aspects can only be a good thing. That's fantastic. Thank you so much. Thanks so much