July - August 1999

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

In this column, Donna M. Qualters, PhD, provides community teachers with a tool to improve feedback to students. 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. Submissions should be no longer than 3-4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.

Clinical education was designed to involve students in hands-on application of learned theory and skills, which is reinforced by continuous feedback. Collecting data about students’ learning is gathered from a variety of sources: the learner, staff, and patients. However, the most valuable data comes from what the preceptor directly observes and “feeds back” to the learner. Observation is not easy! Few preceptors have the luxury of observing complete medical encounters or giving feedback immediately after the encounter.

An additional difficulty is that preceptors are not trained to observe as teachers and often make two common mistakes: they try to observe too much in a short time, or they focus too narrowly on a single aspect of the encounter. To be an effective observer, you need to know what you are observing (framework) and have a method to record observations (tool).

Recognizing the importance of observation to student learning and the pitfalls and time constraints involved in observing for the preceptor, the Community Faculty Development Center at the University of Massachusetts Medical School has designed a tool that allows preceptors to make brief (5–10 minute), focused observations and record them in a specific, nonjudgmental language, even if feedback does not occur immediately.

Plus/Delta Sheet
In training preceptors on giving effective feedback, we introduce them to the Teaching Observation Sheet or Plus/Delta Sheet (Table 1). This simple tool has many advantages. First, it is highly portable. While we train faculty using a full-size sheet, Plus/Delta Sheets can be constructed on 3x5 cards that fit in a coat pocket, or they can be recorded on the back of a piece of paper. A colleague even received one on a napkin!

Second, the format of the tool is flexible and can serve multiple purposes. The lines down the side can be used to record the framework and content of what a preceptor is observing. For example, in observing a student interview, observers can list the elements of the interview on the lines. The lines can also be used to record the time, especially if there is concern that a student is not effectively using his/her time in a clinical encounter. A recent Plus/Delta Sheet revealed that one student was taking too much time obtaining the social history of a patient. This information provided the preceptor with concrete data for feedback to the student and helped identify the area where the interview questions could be improved by the student.

The lines can also be used to allow the preceptor to prioritize the amount and order of feedback given to the learner. By reviewing the sheet prior to the feedback session, the preceptor can ensure that the learner receives positive feedback and one or two areas needing improvement without overwhelming the learner.

The plus column is used for recording what the preceptor sees that he/she likes. The delta column is a place to record what the preceptor sees that he/she doesn’t like, feels should be changed, or has a question about. For example, in Table 1, the observer noticed that the patient mentioned alcohol consumption a number of times, yet the student did not pursue this. The preceptor can feed this back to the student and explore the student’s thinking: was it because the student was uncomfortable, was unaware of the CAGE questions, or something else? In filling out the Plus/Delta Sheet, we train preceptors in some key concepts of observation. They are told to keep track of both the content and the process of what they are observing. We ask them to record only observable behaviors. For example, preceptors do not see rapport; they see eye contact, body language, etc. Preceptors are also told to record exact language whenever possible. It often takes practice, but a shorthand can be developed. Feeding back exact language to the learner puts the preceptor and the learner in the same place in the encounter. It is important to tell students that they did not follow up on patient concerns. It is much more effective to tell students they did not follow up on patient concerns and then say, “Remember when the patient said, “I don’t have the money for medication” and you replied, “How long have you been feeling this way?”

An added value of the Plus/Delta Sheet is that there is a record of what occurred during the observed encounter, and detailed, accurate feedback can be given even days after the observation. Many preceptors tell us they keep the Plus/Delta Sheets and have a record of student progress during the rotation and concrete examples to review when filling out final evaluation forms.

In summary, the Plus/Delta Sheet provides a framework for preceptors to do short, focused observations that capture the content and process of what is being seen, records exact language to reconstruct the encounter, and provides a developmental record of student progress over the course of a rotation. This tool greatly enhances the quality of feedback given to students and thus the quality of medical education.

Corresponding Author: Address correspondence to Dr Qualters, University of Massachusetts Medical School, Community Faculty Development Center, 55 Lake Avenue North, Worcester, MA 01655. 508-856-4268. Fax: 508-856-5536. E-mail: donna.qualters@banyan.ummed.edu.