I am preparing to give a faculty development talk in Toronto next week.
So I have been thinking a lot about giving effective feedback to learners, while sitting on the couch as Dave watches the U.S. open tennis tournament. I am watching distractedly in my ADHD way, intermittently riveted by the young American tennis phenomenon Coco Gauff.
There is a lot of discussion on TV about Coco seeking out veteran coach Brad Gilbert. She added him to her team as a consultant after she lost in the first round at Wimbledon. I’m half listening about how his coaching has helped her become a stronger player. He has improved her skills, her strategies and her emotional approach to the game.
Coincidentally, I’m reading articles that advocate using a coaching strategy to teach medical learners, a values-driven and goal directed approach. Sometimes we lose sight of what the prize is in medical education.
In sports there is literally a prize, the goal is very obvious although the best path to get there may be obscure. In medicine, the goal is more complex. It needs to be co-created by the learner and the program so that the student gets to where they need to go. There are indeed three masters to be served in every encounter: as a clinical teacher, each day I have to make sure that the learner gets feedback that will help them improve, that there is good documentation in a field note that is clear and useful, and last but not least, that the patient is properly treated.
Too often we do a bad job. We avoid giving negative feedback, because we are afraid of the consequences for ourselves. We don’t want to feel like the bad guy. We hope that someone else will do the dirty work and tell the learner they aren’t up to snuff. We may not have a clue on how to help the learner improve. And perhaps most heinously, we think if we pass them out of this rotation, we won’t have to see them again, and we can avoid the pain and trouble of remediating them.
In the workplace, it’s hard to find time to actually watch what our learners are doing, especially when we are ‘rubbing shoulders’ because our very presence changes the interaction between the resident and the patient, as surely as it does to Schrodinger’s cat.
We are also dealing with our learners’ very human tendency to only hear what they want to hear, and to ignore any information that does not fit into their self-image. This is particularly true in poor learners, who are notoriously impervious to corrective feedback. We were all taught to use the ‘feedback sandwich’ technique, where our corrective advice is sandwiched between two slices of limp and bland praise. Turns out that research shows that using this technique is . . . how shall I say this? Baloney. The noise to information ratio is too high, allowing our most feckless learners to not even perceive it. As a native Montrealer and old time clinical teacher, I grew up with both the feedback sandwich and the Wilensky’s Special. I know a baloney sandwich can be good, but maybe one would not want to make this the basis of one’s diet.
So back to tennis and coaching: I know next to nothing about sports except, but I live with a sports nut. I’ve listened to him analyze every move in every sport, for years. He’ll often come out with the exact comment the sportscaster is about to say seconds before they say it.
We got to talking about coaching and training. We looked at how Brad Gilbert enhanced Coco Gauff’s game. We read about how he helped her analyze her opponents, helping her gain tactical nuance which allowed her to win even when she is not playing her best game. This is what a coaching approach to teaching medicine can be.
Last week, I was watching a learner doing a first prenatal visit. She was asking all the routine questions without preamble or explanation. I could see the couple getting more and more anxious when she started asking about STIs and herpes, etc. although her voice was kind, the lack of context made her sound accusatory. I went into the room and was able to connect with the couple. They seemed a lot happier by the time I left. Afterwards spoke the learner and I debriefed. I tried to channel Brad Gilbert as I explained what I had seen and reiterated my commitment to helping her.
“When you fire off questions like that, it sounds that you think that you believe that they are sexually promiscuous. In this deeply Christian couple, you can see how that would interfere with creating a good relationship with you.”
We then brainstormed what she could do the next time. “I want you to concentrate on giving a context to your questions and add normal human reactions like ‘congratulations on your recent marriage,’ or ‘this must be hard on you’ when the situation calls for it.” She promised that she would try to do this next time.
As teachers and clinicians, we have to know what a good outcome looks like. We need to be sure that our learners and patients know that we share their goals and that we will bust our butts to help them get there.
Then, like a good coach we have to make corrections, bringing them ever closer to that goal and give them guidance on strategies and tactics in their goal to become who they want to be.