January Family Medicine Listings

For the Office-based Teacher of Family Medicine

January 2000, Vol 32, No 1

Paul M. Paulman, MD
Feature Editor

Editor’s Note: This month’s column addresses the evaluation of medical students as a daily and a cumulative process. Samuel W.M. LeBaron, MD, PhD, and Jay Jernick, MD, are faculty members in the Division of Family and Community Medicine at Stanford University. I welcome your comments about this feature, which is also published on the STFM Web site at . I also encourage all predoctoral directors to make copies of this feature and distribute it to their preceptors (with the appropriate Family Medicine citation). Send your submissions to Paul Paulman, MD, University of Nebraska Medical Center, Department of Family Medicine, 983075 Nebraska Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@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.

Evaluation as a Dynamic Process
Samuel W.M. LeBaron, MD, PhD; Jay Jernick, MD

(Fam Med 2000;32(1):13-4.)

When medical students are asked how their clinical preceptors could improve, a common reply is, “Give us feedback on our performance!” Students need to know how they’re doing now, not at the end of the rotation or weeks or months later. This article 1) discusses the dynamic, integral relationship between daily feedback, teaching, and the final evaluation, and 2) outlines some techniques for providing daily feedback to students.

The process of giving students feedback is crucial to developing a final evaluation that is truly helpful. Daily feedback needs to include frequent verbal comments on strengths and weaknesses, with suggestions for further improvement. Comments may be as brief as a few words (“Nice work on that history.”) or may include a half-hour discussion. The summative evaluation is usually intended to document how well the student achieved a set of expectations for the rotation. Without the context of daily feedback and teaching, the student has little opportunity to relate final comments to any specific behaviors or abilities, so there is little opportunity for growth. From that perspective, the summative evaluation can be seen as part of a continuum that requires daily feedback to be meaningful.

Some Basic Principles
For most preceptors, giving frequent feedback does not occur without some deliberate planning and attention. There are some principles that will help prepare the way:

1) Develop Specific Goals
Begin from the first day to think about the last day. What would you like to say about this student at the end of the rotation? This reminds us to be clear about goals for the student, because our final evaluation will reflect in part the quality and amount of teaching we have provided. Make your goals specific, clearly understood, and within reach.

Consider the student’s point of view. Ask what he/she hopes to accomplish during the rotation. What types of patients, skills, or knowledge should be included? Clarification of both the student’s and preceptor’s goals on the first day is essential for both to develop a learning partnership.


2) Link Feedback to Teaching
In the same way that evaluation is built on feedback, so feedback is built on teaching. Regular critical feedback in the absence of teaching can make students feel as if the rotation is an extended clinical exam, with little growth available to them. On the other hand, teaching with no feedback can make learners feel as if there is little consequence to whether they learn well or poorly. A more balanced diet for the adult learner is frequent feedback and teaching.

3) Demonstrate Friendliness and Respect
Model the same interpersonal skills that you expect from your students. Stop between patients and make eye contact with your student. Smile, and look for opportunities to let students know that you appreciate the opportunity to work with them or that you appreciate the contribution they made to your patient care.

Feedback and Evaluation Techniques
1) Use “Sandwich” Techniques
Consider this feedback: “Your cardiac exam isn’t very good.”

It is more helpful to include areas of both strength and weakness to develop a context with reference points. For example: “I noticed how well you did the lung exam. You spent an appropriate amount of time on that, and you had a good technique. You missed a couple of important points on the cardiac exam, though, and I’ll show those to you. Then you’ll have an opportunity to show me how you’ve improved on the next physical exam.”

Serve the student frequent “sandwiches” like this, comprised of comments on a strength, then a weakness, then a strength or a direction for growth. This helps the preceptor and the student to be clear about both goals and the subsequent feedback—which should be during the next clinic.

2) Help the Student Take Small Steps
Help the student make minor, easy corrections at the time they’re needed. Most physical exam skills are best corrected during the physical exam. However, try to ensure that the opportunity is one that will promote confidence. For example, if the student has a poor technique for handling the otoscope, with a fussy, ill infant who has a difficult ear exam, it may be preferable to take the otoscope, demonstrate the technique, but wait for the cooperative or less-ill child exam for the student to try out your suggestion.

For more complex issues, such as problems with time management or interviewing an angry patient, consider using a brief (30–60 second) comment between patients. For example, if the student had appeared defensive with the previous patient, consider finding a private space to offer some small, specific suggestions for improvement. For example:

That’s a kind of patient who often makes me feel defensive, just like he did with you. I’m glad you didn’t get into a big argument with him. Let me tell you two small techniques that have helped me . . . . Why don’t you think about them tonight, then let’s do a brief role play tomorrow to try it out.

3) Use Mini Evaluations
Use mini evaluations to assess the student’s progress and to ask how well the rotation is responding to the student’s hopes and wishes. Students often point out that, even when they receive daily feedback on specific skills and knowledge, it is helpful to hear occasionally a 30–60 second summary of how the preceptor sees their performance overall. This kind of brief mini evaluation once a week helps preceptor and student notice where there has been growth, as well as where there has been little change. Lack of change (eg, difficulty performing exam of the knee) invites the preceptor and the student to reflect on whether the student needs to do some focused reading or whether the preceptor needs to ensure that they examine two or three knees together during the course of their next clinic session.

4) Design Specific Learning Activities
Give the student a specific learning activity, such as reading on a particular topic or practicing the knee exam. Suggest a specific goal just before the student goes into the exam room to see a patient. For example, consider the following assignment for a student who is unable to stop obtaining an unnecessarily detailed history from every patient, no matter how focused the problem: “When you go in to see the next patient, check your watch. Limit yourself arbitrarily to history gathering for only 5 minutes, then come find me, even if your history is incomplete.”

Conclusions
The final evaluation for a clinical rotation is best seen as a summary of interactions that must take place within a student-teacher relationship. In the absence of daily feedback, a final evaluation is only a superficial, general statement of impressions. Even the best students still need suggestions for areas of further practice or study. Students want and need evaluations that grow out of a dynamic learning process.


Corresponding Author: Address correspondence to Dr LeBaron, Stanford University, Division of Family and Community Medicine, 703 Welch Road, Suite G-1, Palo Alto, CA 94304-1708. 650-725-5339. Fax: 650-723-9692. E-mail: slebaron@leland.stanford.edu.