June 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: I welcome your comments about this feature, and I also encourage all predoctoral directors to make copies of this feature in its entirety and distribute it to their preceptors. Send your submissions to Paul Paulman, MD, University of Nebraska, Department of Family Medicine, 600 South 42nd Street, Box 983075, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@mail.unmc.edu.

Feedback is an essential skill for all teachers. For learners to grow and improve their skills, they need to know what they’re doing well, and they need guidance on how they can improve. While students can and must do self-assessment and direct their own studies, they also need input from those with more expertise than themselves. It is our responsibility as clinical teachers to provide this in the form of ongoing feedback.

Feedback can be time-consuming. In the course of a busy day, it may be tempting to let some things just go by, rather than break the pace of patient care to give timely guidance and instruction. Unfortunately, this practice often results in repetition of errors and may take more time in the long run.

Many of us struggle with giving feedback. The tradition in medical education has emphasized negative feedback; if you did something well, it was quietly accepted, but if you did something wrong, everyone heard about it on rounds.1 On the other hand, in family medicine education, we often encounter hesitance to give negative feedback. Whether it’s due to painful memories of our own learning experiences, a result of the close one-on-one relationship developed during community-based rotations, our sensitivity to emotional issues in general, or other reasons, experience shows that family physicians as a group tend to avoid giving negative or constructive feedback to students. Almost a decade of data from student evaluations of the required family medicine clerkship at Duke shows that faculty are consistently rated lowest on their provision of feedback to students, while faculty are rated highly on clinical skills, enthusiasm about teaching, and other measures. Learners from all four North Carolina medical schools who participated in the North Carolina Academy of Family Physicians Preceptor Workshop Series have voiced strong pleas to the physicians present—they want to hear what they need to work on.

How can we give our learners the feedback they need without putting them through unnecessary pain? Since many of us didn’t experience much carefully provided constructive feedback, we need instruction on how to do it for our learners. And, how do we fit this into our already overwhelmingly full days?

Fortunately, feedback doesn’t have to take long to be done well. There are a few key principles to remember:

1. Plan for Feedback
Feedback is more effective when it doesn’t come as a surprise. In the beginning of a rotation or course, talk about it. It may help to ask learners if they have preferences about how they’d like to receive feedback. You may want to plan daily opportunities (5–10 minutes at the beginning or end of the day, over lunch, etc), as well as schedule slightly longer (15–30 minutes at most) feedback sessions every 1–2 weeks. Discussing chart notes at the end of a clinic session or planning readings for the next day provides perfect opportunities to incorporate feedback.

2. Be Behavior Specific
Give details about what specifically was done well or what might be done differently. Focus on behaviors that can be changed, not personal characteristics or interpretations.

3. Be Timely
Feedback is most effective when it occurs in close proximity to the behavior it addresses. Discussing performance frequently not only benefits the student but also makes it easier for you to remember the details that are so important to convey.

4. Be Brief and Concise
Too much feedback can be overwhelming and isn’t absorbed well. This fits well with item #3, because in the middle of a clinical session, there isn’t time to be anything but brief! It’s often reasonable to select the most important point or two, and leave the rest for another opportunity.

5. Be Balanced
Everyone does some things well, and everyone can do things to improve. Give positive feedback to reinforce what has been learned well. Many suggest starting with something positive, and some suggest ending with a positive as well (the “feedback sandwich”). Always provide suggestions for improvement. If a student is outstanding, and you can’t think of a thing he/she needs to improve, try thinking of the student as a colleague instead of a learner. We all have continuing education needs; what are they for this student?

6. Respect Privacy
Just as we maintain confidentiality when talking with patients, we should give feedback in private.

7. Provide Constructive Feedback
Model for your learners that ongoing feedback and continual learning are part of life as a physician. Your openness to hear their opinions and act on their suggestions (when appropriate) will increase their level of comfort in hearing and acting on your feedback to them as well.

8. Involve Others When Appropriate
Input from your partners, staff, and patients can provide helpful additions to your own observations. If you’re concerned about a student’s performance, or he/she doesn’t seem to be responding to your feedback, don’t hesitate to involve the course director. With a little attention and practice, feedback can become as ingrained a part of your teaching as introducing your student to the patients, and it shouldn’t take much more time.

References
1. Ende J. Feedback in clinical medical education. JAMA 1983;250(6):777-81.

Correspondence: Address correspondence to Dr Kaprielian, Duke University Medical Center, Department of Community and Family Medicine, Box 3886, Durham, NC 27710. 919-681-3071. Fax: 919-681-6560. E-mail: kapri001@mc.duke.edu.

At the same time clinical medical education is moving from medical center to community practice sites, pressures are increasing for community practitioners to maintain high patient volumes and rapid patient flow. According to Usatine et al, many physicians think that one of the most problematic aspects of teaching is balancing it with patient care requirements.1 If community-based medical education is to succeed, we must find ways to cushion the impact that teaching may have on community practices and preceptors, without lessening educational quality. A recent preceptor workshop, “Incorporating Teaching in a Busy Practice,” sponsored by the North Carolina Academy of Family Physicians, generated a number of teaching strategies that lessen the impact of students on a practice. Twelve community-based and five on-campus faculty from the four North Carolina medical schools participated in the workshop and collaborated in developing a list of strategies to address the problem. Of the strategies on this list, one major category is independent student activities aside from direct patient care. These activities focus on developing a broader understanding of medical care issues in the community, thus enhancing a student’s experience, while freeing preceptors from direct teaching for varying amounts of time.

Activities at the Practice
Many learning activities can be assigned at the practice site that do not require the preceptor’s presence. For example, asking the student to look up a topic and prepare a 5-minute summary can enable the preceptor to focus on a patient problem and, at the same time, offer the student an opportunity to assist in finding needed information. The student can be sent to the office library or an on-line database to do an in-depth search if needed for patient care issues. Some activities, such as making follow-up phone calls or accompanying a patient to a subspecialty consultation visit, can help students develop better rapport with the patients they encounter. Other activities, such as working with nurses, lab technicians, dietitians, or front office staff, can help students develop an appreciation for the roles of different members of the health care team.

Out of the Office
Exposure to the demands of a physician’s role outside of direct patient care socializes students into the profession and allows them to appreciate the complexity of the physician’s role in the community. When preceptors have to be away from the office, that time can be used to familiarize the student with some of those other responsibilities. Students can accompany the preceptor to hospital medical staff meetings, nursing home or hospital rounds, or community health screenings. Students might assist in writing an article for a local newspaper or speaking to a community group. Activities outside the office also may involve other members of the health care team. Students can join a visiting nurse for a home visit, investigate or visit other community health resources (eg, nursing home, health department, physical therapy office, mental health facility), or even spend a half day with the chief executive officer in a small community hospital. These experiences will further students’ appreciation for the role of family physicians in coordinating multiple modes of care and increase their awareness of community resources available to patients.

Major Projects
Course curricula may require students to complete projects while on a rotation. Besides allowing time for students to work on that project, the preceptor may wish to assign a limited project that would provide an additional learning opportunity and produce a product useful to the practice. For example, with guidance from the preceptor, a student may be able to produce a needed patient education piece, do a chart audit on a problem of interest, access referral patterns, investigate a potential community environmental health issue, or do a home visit or family assessment.

Summary
Numerous strategies exist to decrease the burden that teaching may place on a busy clinician, while still providing quality learning experiences for students. Independent student activities, both within and outside the office practice, are one useful strategy. With proper planning, these activities can enable students to assist their preceptors and broaden their learning experiences.

Reference
1. Usatine RP, Hodgson CS, Marshall ET, et al. Reactions of family medicine community preceptors
to teaching medical students. Fam Med 1995;27(9):566-70.

Acknowledgements: This project was supported in part by DHHS grant #2 D15 PE84064-04
and by the North Carolina Academy of Family Physicians.

Thanks to Donald O. Kollisch, MD, Dartmouth Medical School; Venita Weaver Morell, MD, Bowman Gray School of Medicine; and George S. Poehlman, MD, East Carolina University School of Medicine, for their contributions to the workshop and paper. Thanks also to Jerri R. Harris, MPH, East Carolina University School of Medicine.

Correspondence: Address correspondence to Dr Kaprielian, Duke University Medical Center, Department of Community and Family Medicine, Box 3886, Durham, NC 27710. 919-681-3071. Fax: 919-681-6560. E-mail: kapri001@mc.duke.edu.