It's a very, it's going to be an awesome presentation. It's going to be very informative. We're going to talk about something we as physicians practice almost every single day, whether with our learners or with our nurses or with our patients. So we'll talk about principles of assessment, how to provide an effective feedback. This session is being recorded, as you know. I am the Muslim Community Chairman. My name is Dr. Al-Awadi. I'm a board-certified physical medicine and rehab specialist in Canada and the United States, as well as brain injury subspecialist. So our objectives are to understand the value of effective feedback, how to identify qualities of effective feedback, discuss the challenges, and describe an approach that has been quite well studied around giving an effective feedback. Next slide. So again, I'm not going to introduce myself again. I'm the Community Director, and I am very thankful for my faculty panelists, Dr. Adil Hussain, Dr. Yusuf Chowdhury. In the next slide, Dr. Shahid Haider and Dr. Sanas Siddiqui. Next slide. This is like a quick, gentle reminder on how to join the Muslim community. Again, if you have any questions around that, feel free to reach out at the end of the presentation at any point in time. And I am more than happy to guide you through that. Next slide. So there has been a lot of pearls of wisdom on how to provide effective feedback. One of them by Churchill, which I really like, a criticism may not be agreeable, but it's necessary. It fulfills the same function as pain in the human body. It's a different kind of pain though. It calls attention to an unhealthy state of things. I like the third one as well. The single biggest problem in communication is the illusion that it has taken place. And believe it or not, as physicians, we are very good at saying something and we mean it in a lot of different ways. I have been encountering that a lot throughout my residency fellowship and currently being a faculty member. Next slide. So probably this is just a gentle reminder on the learning objectives. Again, I'm not gonna go through that again. This is just going throughout the presentation. Next slide. So before we start the effective feedback, we'll go through a feedback scenario that I am pretty sure a couple of you have gone through that, you have seen it. I'm gonna give you a quick kind of introduction. So I'm gonna be the PM&R program director who is giving a feedback to one of my students, Dr. Yusuf Choudry, kindly agreed to be the student. So before we proceed with the scenario, I would give you a quick kind of introduction why we are heading to that route. Next slide. So Yusuf is a fourth year medical student starting his four week elective rotation in physical medicine and rehabilitation. He successfully matched into orthopedics residency in Mount Sinai, New York. Awesome, that's an achievement. He's trying to get a general idea about what rehabilitation medicine is and how it's connected to orthopedics, which definitely pay off in his residency. At the beginning of his rotation, he received the objectives of this rotation that includes but not limited to appreciation of common medical conditions encountered in the rehabilitation population, demonstrate appropriate documentation skills, how to be professional in being involved in other team members in patient's care. The only reason I mentioned the rotation objectives are not limited to these four because we usually have a big packet or a booklet that follows the ACGME accreditation. Slide. During his first two weeks, Yusuf was consistently 20 minutes late in the morning rounds. He was told a couple of times by multiple staff members to make an effort to be on time. He also did not write progress notes for all the patients to whom he was assigned. So as a medical student, you start gently with two patients and then build up as their comfort zone increases. He wasn't even able to comply with the demands of two patients' progress notes. When the staff physiatrist asked him some basic knowledge questions, Yusuf was unable to answer them coherently. Yusuf did, however, show some empathy toward his patients. This behavior was observed by multiple physiatrists, including the program director. The program decided to provide Yusuf with some feedback on week two. And the only reason I'm mentioning week two is it's important to reemphasize on when you give a feedback, you need to measure the carryover of the information and implementation of the feedback. So he was given this feedback on his performance in order to see improvements. Yusuf is now meeting with the program director in order to discuss his performance. Thank you, Yusuf, you're on board. So the meeting was held in the program director's office, which is mine. So myself as a program director, I will start. So I'm already sitting with Yusuf. So Yusuf, how is your elective going? Going well, thanks. Do you have any concerns or issues you want to discuss? Not really. Since you have no concerns, I'll go through a few things we have noticed during your rotation that we would like to discuss with you. Are you open to hear about them? Yeah, sure. Great. So first of all, you're a nice person to work with. We as a team have noticed that you have a great attitude towards patients. You show empathy and you're easy to work with. Thank you. However, we as a team have noticed that there have been some behaviors that are a bit concerning when it comes to safety in medical care. For example, you have persistently showed up in the morning rounds 20 minutes late. This reflects that you might be having some issues with morning rounds. However, this also reflects that you might not be interested in the morning rounds. What do you think about that? No, I'm trying to get used to a certain routine. My last rotation was in the emergency room, so I had a lot of night shifts. I have been having a difficult time waking up for the morning rounds. Yeah, okay. We have also noticed that you did not write progress notes on all the patients you were assigned to take care of, like two patients as a start, and then we're gonna build it up for better. I think by Med 4, you should be able to handle a greater patient load without any difficulty in terms of note writing and time management. You know, the way the notes are written in rehab medicine is a little different. It involves the medical and the rehab part, and I'm just still trying to figure out how to master it. I am working my best to achieve the standards you're looking for, though. That's fair. I can guide you through the writing notes in rehab medicine that resembles kind of internal medicine, but on top of that, we have the functional approach and the quality of life. And just to keep this observation in your radar as well, as per ACGME competencies, being a knowledgeable person is a long process. Myself as a faculty, I'm still learning. I'm still teaching my students, my residents. There are some expectations to be achieved at Med 4 level. You have any suggestions on how to work on that, how to troubleshoot it? You know, I'm taking everything you're saying very seriously and I'm gonna work hard to overcome these obstacles and get the maximum experience out of this rotation. That's great. Since we clarified these things between us, I would suggest that you report to the morning rounds early, show interest in the medical aspects of the patient's care, ask questions, if any, write notes on a daily basis. I'll give you a theme or a template that you would follow through. And again, every patient is unique, but we can work around the template as a start and ask you some questions about common medical scenarios that you might encounter throughout your career. Does that sound okay? Yeah, that sounds reasonable. I really appreciate you coaching me through it as well. So next Wednesday, we'll sit together and go through your progress notes and see how are you overcoming your challenges and if there is anything else we want to go through. That's great. I'm looking forward to see you shining and getting the maximum experience out of this rotation. Thank you for your feedback, doc. I really appreciate it. Well, I'm going to get back to the presentation. We're over with the scenario. How did it go? So it's a poll question and I'm waiting for answers. OK, I'm going to give another 10 seconds and I'm going to spread the results. All righty, so we can see that it's kind of 50 50 from very good to good, which is I really appreciate that. OK. So we're going to move on again. I'm going to give the lead to Dr. Hussein to talk more about giving feedback, and the rest of the team will come along with the presentation. Hello, everyone, my name is Dr. Hussein, I am a board certified physician in physical medicine, rehabilitation and brain injury medicine, working at Rancholis in the U.S. National Rehab Hospital in Downey, California. So I'm going to talk a little bit about giving feedback, some different types of feedbacks that are available. And hopefully trying to overcome situations in which difficult feedback is needed to be given. OK, next slide. So just a couple of definitions of feedback, when a learner is offered insight into what he or she actually did, as well as the consequences of his or her actions. Therefore, feedback highlights the dissonance between the intended result and the actual result, providing impetus for change. So that's really what we're trying to go through here, is that we're trying to provide positive feedback that will result in an impetus for positive change in the learner. Effective feedback may be defined as feedback in which information about previous performance is used to promote positive and desirable development. And again, the goal here is to develop learners who are able to take in information about their previous performance and be able to improve upon that for future rotations. Next slide. So why is it important? I feel like this is kind of an answer that we all know, but just to highlight some key phrases. It's known that students who do receive regular feedback perform significantly better as they progress through their training. So from PGY-1, 2, 3 and beyond, the more and more feedback they receive, the better and better they are able to hone their skills and knowledge and ultimately end up as best as they can by the end of their training. It also allows students to develop better judgment because sometimes you're not able to judge a scenario unless you have feedback on how things are going. And it also allows them to learn faster. Again, one of the types of tricks that we fall into is that if we don't receive enough feedback, we end up falling into the same habits that we are used to performing in the past. And therefore, we're not able to learn or develop further in terms of our clinical acumen. Without feedback, mistakes do go uncorrected. Good performance is not reinforced. So again, this is not only when you need to provide feedback on someone who is performing substandard, but also when someone is performing well. If you're not reinforcing that behavior, then it may slip or the learner may self-validate, meaning they are basically left to try and fend for themselves in terms of figuring out how they're doing. And they may not repeat good behavior, as well as they may repeat negative behavior. So we're trying to basically hone those. And then, of course, clinical competence is often not achieved through regular feedback, through the facilities that we mentioned earlier. Next slide. So this is another poll question. We'll have everyone, if they can, type answers into the chat box. Using one word, what would life without feedback be like for you? I'll give it a little time. All right. So some of the responses include chaos, no guidance. That's true. I mean, ignorance, that's another good word that's used to describe what things could be like, and confusing. These are all different types of situations, no direction. Some of the words that I had developed, aimless, random, disorganized, wasteful. This is kind of, I mean, if we're looking at an outpouring of feedback, if we're looking at analogies in terms of the picture that we see, we have someone who's trying to hit a target, but they're not able to do so because they're not getting any feedback to guide that arrow towards the target. Next slide. So you see, when we are able to provide feedback in the form of both formative assessments, and it will allow you to reach a much more positive experience in your final summative assessment. So basically, taking a look at the slide here, you have a learner who is going in the wrong direction. He's trying to hit the target, but he's aiming really, really far too down. You give a formative assessment kind of at the two-week period, like how Dr. Al-Lawadi did with Yusuf, and you're able to redirect the learner towards hitting their target. A formative assessment is essentially basically giving... It's when you monitor learning and provide ongoing feedback. So this is done during their rotation to continue to monitor their learning and provide ongoing feedback. Say they move in the opposite direction and overcompensate, another episode of formative assessment, perhaps at the four-week period, would again allow them to hone their skills and their ability, and they would be able to reach their target during the summative assessment. And the difference between a formative assessment and a summative assessment is that the summative will evaluate student learning at the end of an instructional unit and compare it against a standard or benchmark, such as the ACGME standards for each PGY year. So it basically allows you to continue to allow the learner to reach their end goal by the end of their instructional unit. Next slide. So again, life with feedback is when you can use your arrow to hit the target square on. Next slide. So I want everyone to kind of think a little bit to themselves. How are we doing? How was the feedback that you received during your training? And how comfortable are you in giving feedback to others? Next slide. Some of the studies that have been done in regards to giving and receiving feedback show some interesting results. Often, medical trainees feel that they receive poor or insufficient feedback during their rotations. And this was shown by Dr. D. Henke-Aliwadi et al. in 2005. There's also a discrepancy in how feedback is given and received by McGill, Sander, Lieberman et al. in 2005. And the space for written commentary. So you'll see often on ACGME surveys at the end of our rotation, after performing that summative feedback where you mark how well a learner is performing based on the ACGME standards per PGY year, there's often a little open area left open for freehand texting about how you feel a resident has done or a learner has done during their rotation whether that be a medical student or resident. That little space for written commentary is often found to be empty or vague and nonspecific. So for example, there'll just be a comment in there, a student needs to read more or a student did a good job during their rotation. Even whether that be negative or positive feedback, it's far too vague and simplistic, nonspecific. It's not really going to help the learner be able to move forward in terms of their own clinical acumen. So performing those formative assessments as we talked about earlier before the summative assessment and just typing in, word dumping your thoughts into a commentary box would be much more effective. And so what we'll talk about next are some of the issues in giving difficult feedback and some of the strategies or different types of feedback that you can give in order to address difficult feedback. Next slide. So again, think to yourselves for a moment, what kind of feedback do you find difficult? I know I definitely have an answer in terms of the residents that I supervise. What kind of feedback I find difficult? Next slide. And here are some examples. So you all know the ACAGME general competencies that we're trying to achieve. Some of the barriers in achieving those competencies include a poor knowledge base in terms of the professionalism competency. Learners may present with poor hygiene. They may be disinterested. They may demonstrate inappropriate behavior. They may be overconfident or challenging. They may not excel in terms of their written verbal or nonverbal communication, what type of body language they put out. All these things that we notice in the different learners that we supervise, we should be able to provide feedback for those. Now, it can be difficult. However, you don't want to come off as someone who is too criticizing. You don't want to hurt the confidence of your learners. You also don't want to misunderstand perhaps a scenario that you don't fully understand about a learner. Maybe they're going through something in their personal life, in which case we'll talk about the type of feedback that you can elicit to try and learn more about that and try to adjust perhaps expectations or maybe even adjust what we're trying to achieve during the rotation. And that's what we'll talk about a little bit in the next slides about what types of feedback that we can provide based on the situation that is presenting itself. Next slide. So again, so we'll talk a little bit about some of the different types of feedback, okay? So say you're in a situation where a learner has an illness or a death in the family or they're having some type of relationship issues. Now, the appropriate feedback scenario and this may be something called affective feedback. And affective feedback is when teachers display signs about how interested they are in trying to understand the student through gestures, facial expressions, and intonations. Positive affective feedback will encourage the learner to continue even if it is clear that the listener cannot fully understand the situation. So affective feedback is essentially you as the mentor, as the teacher, you are displaying through your thoughts, your intonation, through your gestures that you want to know more about the learner's situation, what they're going through, even though you personally can't fully understand it since you're not the one who's experienced, for example, a death in the family, you show that interest and you show that willingness to learn more about their situation so you can understand how they're doing. And that's what's known as the affective feedback. Conversely, we have cognitive feedback. So say you have a situation in which a learner is having some difficulties with communication or synthesizing information. They have a poor knowledge base. Cognitive feedback is when you communicate that you know the learner's cognitive abilities and you are able to understand what they are trying to communicate. Okay, so basically you are able to witness problems with communication that the learner is displaying or their poor knowledge base. You as the more experienced teacher, you're able to understand that and you provide cognitive feedback to let them know that, hey, I understand what you're trying to communicate. Let me try to help you structure it better so that you are better able to display and more effectively communicate what you are trying to say. Or you can correct their knowledge base and let them know about what error they have in their thought process or their thinking or in their clinical deduction and provide essentially cognitive feedback directly and being able to mentor them and apply that skill and art. Next slide, okay. So then there's also, say you have presented with a learner who has poor time management or is disorganized. Structural feedback is an excellent way to provide a scaffold in which the learner is able to build upon and be able to overcome these barriers, okay? Structural feedback is basically you as the teacher applying knowledge that you may understand about how to develop a SMART goal, right? A goal that is attainable, a goal that is time-based, a goal that is sustainable and reachable. You can apply that SMART goal towards their time management skills and be able to achieve a positive end towards the end or towards the middle of the instructional unit. You provide that structure and scaffold to allow the learner to build upon so that they can move forward in terms of their learning. And then interpersonal feedback. So say you're presenting with a situation in which a resident or a student is not interacting well with the team or the patients, they're shy, they have poor social skills or even they're manipulative or confrontational. Interpersonal feedback is feedback in which you effectively communicate your feelings and perceptions about how the learner is displaying or presenting themselves, okay? Many times learners, they're not able to really understand how they are presenting themselves towards other staff members, or they may be ignorant about how maybe certain things that they're saying are coming off as. So interpersonal feedback is when you let them know, hey, I've noticed that you haven't given much feedback or information in team conference regarding a patient's progress. Let's talk a little bit about how we can build up some more confidence so that you feel like you would be able to share a little bit more. Or just so you know, the way that you're presenting yourself in team conference is that it sounds a little bit confrontational and that's how it's coming off as. Let's try and discuss a little bit about that so that we can see maybe how we can communicate more effectively. So it basically holds up a mirror to the learner and allows them to see how they've been doing and make those corrections while you are there to guide them. Next slide. Okay, so then another poll question that I wanted to ask within the chat box. Think of a time when you failed to provide effective feedback to a learner. What went wrong? So, a time when I had a resident who showed a lot of disinterest in team conference, they would often be looking at their phone inappropriately during team rounds or morning presentation. And I've had multiple staff members or team members tell me that the patient, the resident seems disinterested in their rehab rotation. I was a new attending at the time and I failed to provide effective feedback regarding that. And what ended up happening is that resident moved on to a different rotation in which she experienced very similar negative perception amongst her and her team, resulting in a poor outcome in terms of her final score during that rotation. So because I noticed negative behavior in a resident and I did not provide feedback, I did not try to, you know, institute a formative assessment or provide some of that interpersonal feedback during their rotation, I just let it slide. What ended up happening is that resident didn't learn from their mistakes. They weren't able to, you know, move towards their goal. They were more aimless and random and they ended up having a negative outcome. So again, we need to try and work a little bit harder in terms of providing that effective feedback and being able to move forward to help those who we are trying to mentor. And I see in the chat box, what if it's a language barrier? That's definitely a difficult, you know, scenario that we encounter. Often as we mentioned, it's not only language, the verbal language that we speak, but also body language and nonverbal communication that is often, you know, presenting itself. So you know, if it is a language barrier, if it is a cultural barrier, I would say the more communication that we are able to bring forward between the learner and the student would be better in terms of trying to overcome. It's all about, you know, the perception that they are giving off and whether that be through a language barrier or through nonverbal body language, as long as we're able to communicate more effectively and more often, we would be able to reach a medium in which they would be able to perform well and we would be able to perceive them well as well. All right, and next, for the next slide, I want to pass the mic over to Dr. Siddiqui. Good afternoon, everyone. Thank you, Dr. Hussain. I am Dr. Siddiqui. I'm board certified in PM&R, and I work in a community and academic setting at Loyola University in Chicago, Illinois. I'm going to talk a little bit about some of the current issues with providing feedback. So as you know, you know, I mean, as a medical student, as a resident, you know, you're rotating through multiple different settings. Sometimes we're in clinic settings. Sometimes we're in ICU settings. Sometimes you're in the OR. So the places where feedback is going to be provided is very complex, very diverse, and sometimes there is a huge turnaround in the attendings that are there, whoever is on service at the time. So sometimes you don't actually have the opportunity to have that time to actually observe and provide adequate feedback, and sometimes it just kind of gets shifted down the line where you just assume that somebody else is going to provide that long-term feedback. Lack of training. Unfortunately, there's not a lot of specific evidence out there on how to provide adequate feedback, and most of the methods that we have now are not necessarily evidence-based. Sometimes it's based off of your own past experience, or it could be based off of, you know, maybe an ACGME form that you're filling out, but not necessarily something that's, you know, evidence-based, and then there's a lot of inconsistency in between, you know, from attending to attending. Then there's time, you know, especially, again, when we're in high-stress, you know, environments, you know, it's not necessarily on the forefront of our minds to, you know, take the student aside and actually provide them with, you know, feedback on, you know, what went well, what could have been done differently, what they can work on moving forward, you know, there's a level of burnout that just exudes throughout every level of training, and, you know, unfortunately, it's just not something that's made a priority. Next slide. Some other feedback issues, one is beliefs that it is futile, or that, you know, the students should already know what they're doing well, what they're not doing well. There's a certain expectation that, you know, students are going to be self-learners, or self-taught, and that, you know, just by being there, just by being, you know, a mentor, and just by, you know, doing teaching rounds, that that in itself is enough feedback, and not realizing that, you know, you do have to have that one-to-one time. And then it's, you know, there is definitely this medical culture where it's a very hierarchical model where, you know, the attending just kind of comes in, they say what they want to say, and that they've given the feedback, and it's not really this, you know, dialogue, it's more of just kind of like a mandate that's put out, and then this expectation to comply. Next slide. And then there's the social aspect. I know Dr. Hussain kind of touched on this a little bit, is that, you know, you kind of don't necessarily, you don't want to come off too aggressive, you don't want to hurt anybody's feelings, you don't want the criticism to be, you know, taken the wrong way. How are you going to be viewed going forward with other students, if you're going to be liked, if you're going to be viewed as, you know, a harsh critic? And then, you know, the fear that this is going to somehow damage that, you know, teacher-student relationship. Next slide. So, we're going to get a little bit into the research and the theory that supports feedback. Next slide. So, in theory, feedback should prompt learning. It should reinforce or modify behaviors. So, if a person is doing well, it should encourage them to continue on that path, continue reading, continue taking care of their patients. And if they're not living up to the expectation of the rotations, that they are then analyzing their behavior and modifying it going forward. It also enhances self-awareness. So, really having that self-reflection and, you know, looking inwards and seeing, you know, what areas you can improve in, whether that be clinical or interpersonal. And then, it also is very dependent on the type of relationships that you are building with your students. Next slide. So, as I said, you know, unfortunately, there is not a ton of literature that gives us that evidence-based guideline to provide feedback. So, it's relatively broad. Most of it has come out pretty recently. And there haven't been a lot of really good, you know, randomized controlled trials on actually how to provide that kind of feedback. Most of the research out there is pretty low-level evidence. Next slide. So, this is just a poll question. So, I know Dr. Hussain had kind of talked about a time where, to think about a time where you had maybe failed to provide effective feedback. So, I would ask the opposite. You know, what is a time where you succeeded in providing feedback to a learner? And why was it effective? Why was it different than the time where it wasn't so successful? Were you maybe in a different environment? Did you have a different relationship established with the student? Did you have a longer period of time to actually assess that student? So, what was different? Next slide. So, somebody commented that, you know, one of the differences was that you were able to provide earlier feedback, so you had time to see that carryover. And that's certainly a very valid and important point that I will get into in just a little bit here, is making sure that you are providing timely feedback so that the learner does have time to then modify their behavior going forward. So, what are the components of effective feedback? Number one, you want it to be very deliberate. You want it to be specific feedback to that learner and to that specific rotation. You want it to be relevant to the learner. You want it to be something that is expected and timely. And then you also want it to be shared. So, I'm going to explain these a little bit. Next slide. So, this is a nice little pearl. Feedback can promote learning if it is received mindfully. So, feedback goes both ways. It, you know, it needs to be presented in a way that it is well received. And then when you are receiving feedback, you need to know that it is coming from a place of encouragement, is coming from a place to, you know, provide an environment where you are able to self-reflect and then make positive changes going forward. Next slide. So, Dr. Hussain had also talked about this a little bit. I'm going to go into a little bit more detail with the differences between a summative assessment and a formative assessment. So, a formative assessment is something that is ongoing and that's going to occur throughout the process. It's going to convey information rather than just a final judgment. And the goal is to make improvements as you're going forward as opposed to more of like a decisional approach. It's very personal. It's very reflective. It's interactive, which I think is key. You are asking for not just that person to sit back and take in what you're saying, but also provide their own personal feedback and, you know, maybe explanations as to why, you know, they've been engaging in certain behaviors or why they haven't, you know, been as engaged. It should be midstream. So, meaning that it should be provided at a time where there is more time going forward to either reinforce or modify the specific behaviors that you're discussing. And then it should be prospective rather than retrospective. So, you know, what goals are being met? What can we do to continue to meet these goals? As opposed to just kind of looking backwards and thinking like, okay, how did this go? Did we meet our goals or not? Next slide. So, again, just formative versus, you know, a summative feedback. Both verifying and elaborative feedback can be effective. And then whether it's directive or facilitative. So, you know, facilitative is, I would say directive is better for, you know, more novice learners. So, when you have, you know, your PGY1s or your MS1s who just kind of need to learn the basics. But when you get more into like MS3s, MS4s, and then later on in your PGY4 years, and then kind of more facilitative so that people become, you know, critical thinkers and are, you know, honing in on their own practices. Next slide. So, feedback should be specific. Sometimes, I know we kind of discuss a little bit like about the chat boxes at the end of our assessments and how, you know, we're providing very vague, you know, nonspecific assessments of, you know, what the experience was. So, it just seems that, like, it's not geared toward that specific learner or that specific experience. And then, you know, the student isn't really taking much away from it. On the other hand, you know, you don't want it to be so specific that you are, that the learner is now essentially mimicking, you know, the attending's way of practicing. You want them to develop their own way of practicing, develop their own personality, while still, you know, meeting and conforming with, you know, gold standards. Next slide. It should be relevant. So, kind of touching on what I had just said, you know, it should be something that is relevant to the practice, relevant to the specialty that they're in, and it's not just something that, you know, is a personal preference, but rather this is something that is standard of care. Next slide. So, it should be expected. So, you know, ahead of time, you know, setting down a timeline as to when they can expect that type of feedback so that the student isn't taken aback, they don't feel that this feedback is coming just because they're not meeting standards, but that this feedback is going to come no matter what. So, at the beginning of a rotation, you can say, hey, look, you know, at the two-week mark, you know, we're going to sit down together, we're going to talk about what's going well, we're going to talk about, you know, what areas we can improve in. It's an opportunity for you to also give feedback and let, you know, let me know, you know, what areas, you know, you would like to learn more about. And so, just setting that expectation ahead of time so that the student is also mentally prepared, and then if there are specific things that they would like to discuss as well that they have the opportunity to prepare to do that. And that then also makes for less of an emotional reaction where they don't feel that this is necessarily a personal attack or, you know, attack on their practice, but more so this is just the standard for the feedback that you're going to be providing to them. Next slide. So, timely, again, you know, you know, having more of a summative assessment, you know, doesn't allow for the opportunity for the learner to then change or modify their behavior throughout the rotation and improve. So, you want it to, the feedback to come earlier rather than later, and but at the same time, not have it be so early where they haven't actually had an opportunity to even demonstrate all of their skills and, you know, kind of think about how they're going to modify their practice for the rotation. Next slide, please. And then it should be a shared experience. So, again, you know, we don't want to have this kind of monologue where, you know, you're just sitting there and, you know, giving this, you know, directive feedback, you know, it should be an open conversation where there's a back and forth where the student can explain, you know, what struggles they've been having, what questions they have, and then, you know, we can kind of open up that conversation a little bit. And that then helps to also accept the feedback that's coming forward. So, it's not seen as, you know, something personal or something aggressive. It's something that, you know, hey, we're here to help you. We're here to learn. And then that feedback can then translate into other rotations, other scenarios, and other aspects of that specialty. Next slide. Okay. And with that, I am actually going to pass along the baton to Dr. Popp, Dr. Chaudhry. Hi, everyone. Yusuf Chaudhry here. I'm board certified in PM&R and pain medicine, and I'm also Dr. Popp of Doctors Bopp and Popp. We're two physiatrists educating children through original music and videos. So, check us out. We're on all streaming services. So, just carrying over now, the idea of giving feedback, as all the presenters previous to me had said, to either students or residents can provoke anxiety, both in the person providing the feedback and the person receiving the feedback. So, a good goal for medical education would be having a systematic approach, one that's ideally evidence and theory-based that we can all use as a template for how we give feedback going forward. Next slide. Here, you'll see multiple different approaches to giving feedback. And while looking these up, all of them provide a systematic method, number one, to identify what the problem is. Number two is to discuss that issue. And number three is to provide an action plan. And, you know, the ultimate goal is improvement. Next slide, please. So, not to be confused with R2-D2, the droid, we have the R2-C2 model, which R2-D2 is a helpful reminder. It's one of our approaches to feedback that's both evidence and theory-based. And it was created by medical educators around the globe. Actually, as you can see, Canada, the United States, United Kingdom, Netherlands. And the ultimate goal with this is that feedback improves performance, especially when it's task-specific. And we don't want to provide feedback that can be harmful and lead to a deterioration of performance. Next slide. So, what does the R2-C2 model mean? So, R-R-C-C. Number one, you want to build rapport and create a relationship with who you're going to be providing this feedback to. Number two, you want their reaction to what type of feedback you're providing. And then the C, the first one, is the content. What is their understanding of this content that you're providing to them? And the last C is the coaching, basically providing an action plan. Next slide, please. So, just, you know, building upon this a little bit further with the R2-C2 model, let's go back to the first R. So, building a rapport, establishing a relationship. You know, you really want to build trust with the person you're talking to. You want to be someone that they find credible, someone that they're going to listen to. And how do you do this? Open-ended questions. You know, we're all pros in that at this stage of the game. So, tell me about your experience. I'd like to hear about your practice. You know, that sort of thing to open it up and create that relationship. For number two, it's really all about their reaction. So, what are your initial reactions? Was there anything that I said that surprised you or that you found striking? And how does this compare with what you thought was happening? Did you think you were doing better? Did you think you were doing things differently than how we're finding you're doing things? Next slide, please. And then going over the content, you know, the simplest thing is, is there anything that didn't make sense to you? And what you want to do is go through this content section by section for them. Make sure they're clear on what this meant and how you can provide them an opportunity for change. The last C is coaching. And this one is really my favorite. And I feel like if we all did this, we can make a huge impact in medicine across the board. It's really an achievable action plan. So, you ask them, what is your goal? How can I help you with this? And then maybe ask them, the most important question of all is, six months down the line, what, if anything, would you like to see changed? You know, and imagine if every interaction in medicine, you learned one thing from that teacher, how far you'd come along. And now I'd like to pass the torch to Dr. Heider. Thank you so much. I appreciate it. All right. So, I'm just, I'm going to give a little summary for what we've learned today. I think we've had a really excellent group of presenters here, and I appreciate you all being engaged and involved. So, just as a summary, when we talk about giving and receiving feedback, who do we want to include? So, we really want to be first-hand providers. As physiatrists, you know, on an attending level, you really want to be giving first-hand observation. You really do want to be sure that you're the one who has been evaluating the said student. I apologize, I just muted myself there. You want to be able to be collaborative, so you want to have a team effort. Both the learner and the attending, giving the feedback needs to be in collaboration and there needs to be a combined effort to have that learner excel. Of course, as we talked about, you want to have a credible competent source. You don't want to be giving this off-handed third-party. If you can help it, you want to try to be giving direct feedback as opposed to a third-party, telling a learner that a physical therapist on X day thought that you had a bad attitude or something. You want it to be as objective as possible and you want to be the credible competent source. Of course, you want to have self-assessment from the learner, so you really want the learner and if you are in a learner's position, which I think at any level we all are, you want to be able to do some introspection and be able to appreciate the feedback that's been given to you. Next slide. Then when we talk about content for feedback, we want to make sure that it's based on performance, actions, behaviors, and decisions rather than things that are subjective, rather than things like intentions or interpretations and personality traits, which again, as we showed in our example previously for our wonderful actors that demonstrated that we don't want to really focus so much on personality traits. Then we want to make sure that we're optimizing patient safety. This is what we talk about being limited to remediable behavior. This is something that can be objective and fixed and specifically related to patient safety and promoting their health care. Again, we really don't care as much. I mean, we care, but the things that we really want to focus on are things that are more objective and that can be really fixed rather than things like an arrogant attitude, things like that. Then of course, we want to make sure that it's relevant. Next slide. Then when we talk about where, I think it's really important to give feedback face-to-face and in a safe learning climate. The last thing you want to do is chew out a medical student or a resident in front of a huge group of people that just, even if you're giving good feedback, it can be just completely taken the wrong way and ultimately, you're losing the whole purpose of what you are intending to do. Then there's always feedback on the fly versus privacy, and I think there's a role for both of those types of feedback as we discussed. But making sure that that learner is in a position to be open and receptive to feedback is very important. Then of course, there's informal and formal feedback. Again, planning in advance that we're going to have this formal sit-down meeting, that's important for providing feedback, but then you can also always give informal feedback. But again, it's just making sure that that learner is receptive and accepting to that type of feedback in the appropriate setting. Next slide. Then when we talk about the when, this should be something that's frequent, ongoing, timely. Again, this is just a lot of repetition of what we just discussed, but that the recipient is receptive and that it's labeled as expected, and that it's expected and it's labeled as feedback as opposed to just trying to be a jerk, for instance. Trying to ensure that the learner knows that it is in good conscience, that we as people who are teaching medical students are in it for the betterment of the learner. I think if you frame it appropriately, then you'll find that learners are much more receptive. Just making sure that that's always a prerequisite to beginning any learner-teacher relationship. Next slide. Then how? We want to make sure we're not overwhelming learners with a huge amount of information. Again, going back to the demonstration, for a lot of people coming through and rotating in our field, this might be the very first time they ever think about PM&R, even explore what physiatry is. It's really our opportunity to inform them and educate them, but with small digestive bites of feedback as opposed to sitting there for two hours with this huge lecture on the Ranchos Los Amigos scale. Sorry, you brain injury people here. But rather than going through big things, just focusing on one pearl per half day. For me, I'm the medical student coordinator at the University of Michigan, so I always pick up one pearl per half day. One of the first ones that I do is extension versus flexion-based back pain. Another one that I talk about is the FIMS score. One good takeaway per half day, I think, is a good goal. Some people may do it a little different, but in general, we like small. That was just me talking about teaching rather than feedback. I'm sorry, but it's still good advice. We want to do descriptive, specific, non-evaluative, and non-judgmental feedback. Again, we don't really want to be biased. We want to try to be as objective and clear as possible. I think these things go a long way and will help students and learners and residents really, really optimize their future. Again, I think we're all on the same page and this is just a good advice to try to promote the next generation of physicians and physiatrists. Next slide. In conclusion, the literature on feedback is relatively broad and it lacks rigorous models. This is why we presented today. Settings, lack of training, time, beliefs, as well as cultural and social factors, make giving feedback pretty challenging. Our goal today is to hopefully give you some advice on how to give feedback that is deliberate, specific, relevant, expected, timely, and shared so that we can be as effective as possible in clinical settings. Then of course, our role as leaders is extremely important in being able to, like we said, produce a really wonderful group of next generation of physicians and hopefully physiatrists, so that they then too can become good teachers for the next generation to come. Next slide. Here, I can't take credit for any of this, but here are the references that Dr. El-Owadi put together here. With that, I'm going to hand it back to Dr. El-Owadi just to give last words, but I appreciate all of your attention today. I would like to bring everybody, my team back to the stage so you all can share your cameras and the room is open for any questions. Thank you all. That's a very good point, 360 feedback. It's one of the components that we use in our residency training that you get from multiple sources. So from the social worker, physical therapist, occupational therapist, and your question, how does it work for a learner to share with the attendings? I'm not sure if I'm getting this correctly or not. What do you mean by that? How does it work for the learner to share? Oh, give feedback, yes, of course. I mean, to be honest, as a part of the training, the first question would be, or like, after giving a feedback, is there any feedback from the student to me? Because it's a two-way reaction. I wanna improve myself as a faculty, as well as I want my student to improve. So being a faculty, you gotta be very open with suggestions. It should be professional, though, behavior, nothing personal. And I think that having that clear communication from the get-go with the student or the resident is gonna be quite vital. Any comments from my team is welcomed. Yeah, I agree with you, Dr. El-Awadi. I think that's one of those things that it's always challenging. I do welcome students and learners that work with me to try to give me feedback as well. And I usually kind of open that way. For me, that's a good way to kind of open the stage or kind of just invite, you know, so I just basically begin by saying, how's your rotation been, any issues, like you kind of had done in the demonstration. And then I hope that you've been learning a good amount and that you've had a great experience. Is there any feedback you'd like to give to me? I usually kind of start that way, just to set the stage, but certainly I think it's appropriate to be done after you give feedback. But sometimes because it may be perceived as punitive, you know, a student, I would imagine, may not be as open to giving that feedback. Yeah, I can tell from a personal experience. I mean, I used to be very quiet. I'm like, oh my God, if I'm gonna say this, how it's gonna be played out. But then as I get senior, I'm like, and doing my master's in medical education along with my residency, allowed me to have that courage and say, no, I think we can work it out that way. How about you as a faculty, this is what you like. This is me as a senior resident, wanna do it this way. Let's combine it together. I mean, yeah, I had to, my master's was a great weapon for me to know how to have that conversation. So yeah, I'm getting all the credit. Any other questions? Alrighty, I think we are, we covered the whole hour. I really appreciate my team. Thank you all. I wouldn't have done that without you. Thank you, Sean, for making it easy and a smoother ride. And yeah, I'll see you later then. Take care. Great job. Thank you so much, Dr. Iloatu, for everything and all of your help. You did a wonderful job. And we certainly could not have done it without you. So thank you. You're a team. I don't take a credit. I'll take some. Take care. Bye-bye.

effective feedback

medical education

challenges of giving feedback

R2C2 model

specific feedback

safe learning climate

face-to-face feedback

ongoing feedback

learning improvement