Yesterday, during yet another excellent session at the ACEP Teaching Fellowship (#ACEPTF14), Dr. Rob Rogers (@EM_Educator) spent some time reviewing feedback techniques with the goal of teaching us many different ways to provide more effective feedback to students and residents. You know, something better than the usual “Strong work” or “keep reading”. We recently ran a similar module with the incoming EM interns at our shop as part of a Resident-as-Teacher workshop, so I was particularly interested in seeing where this would go. Thanks to a great group of folks in the room we had an amazing discussion that really got us all thinking.
One of the more common feedback techniques is the Shit Sandwich (S.S.). This method has become so ubiquitous that, after receiving input from faculty using the S.S., one student reportedly responded to his attending, “Nice Sandwich!” Not that feedback is any big secret. If anything, it is important to state explicitly that the learner is receiving “feedback” (see ALiEM review of Yarris et al, below). But still, there is something wrong with that interaction.
Urban Dictionary teaches us that the Shit Sandwich is:
A way of giving crappy news to someone.The news is dressed up as, first a positive statement then the bad news, and then a positive statement to take the edge off things.
In a way, the Shit Sandwich just makes sense. You disarm the learner by starting off with a nice soft, chewy, sweet slice of hamburger bun. Mmmm. Everybody feels warm and fuzzy, and you’ve bought yourself some good will. Then you bring on the meat/grilled veggies: “Here’s what you’re doing wrong…” Finally, to make sure nobody’s feelings are hurt, at the end of it all you remind them just how great they are by giving another positive remark.
Learners are savvy to this so you’re not surprising anyone. They know exactly when to start paying attention. While you might think they’re enjoying that first slice of bread, they’re just bracing themselves for the bad news to come. And then, when you’re wrapping up that second positive reinforcement, they’re actually still stuck on whatever deflating comment you’ve just given them. All the learner hears is the negative, the two positives just fly right by.
Furthermore, by placing the negative component in such a prominent position – isn’t it the ‘meat’ of the matter? – educators have conditioned learners to think of feedback either as negative reinforcement or as punishment. It is never associated with anything positive. Pulling someone aside for feedback immediately sets them on the defensive. How can we ever reinforce positive behaviors if the mere mention of feedback closes people off?
Finally, it leaves out a component that is essential for adult learners: “Where to from here?” The adult appreciates that their actions have been sub-optimal, but they also need to know what to do better next time.
A Different Way
S.S. has its merits, and I’ve used it and will continue to use it when appropriate. But consider incorporating a new tool into your armamentarium: S-FED. This method, promoted at our institution by several EM educators and by Faculty Development, is based on a paper by Dr. Hershey Bell that appeared in Family Medicine in 2007 (see below).
- S – Self Assessment (What do you think went well during that resuscitation? What do you think you need to improve on?)
- F – Feedback (Open faced sandwich! Split evenly between positives and negatives, build off of ‘S’.)
- E – Encouragement (Empathizing with the learner and taking their side, while simultaneously pushing him or her just beyond “the limits of their knowledge and skills.” See examples in the article.)
- D – Direction (As in what direction should the feedback be taken. How to use the feedback in a productive manner and what concrete steps to take.)
This is a tool that can be used in a variety of settings, including periodic formative evaluations and to give feedback following a classroom lecture. S-FED can even be incorporated into bedside teaching. Take, for example, the 1-Minute Preceptor and its five microskills: Get a Commitment, Supporting Evidence, Teach, Reinforce, Correct. Now let’s modify it. The last two skills – Reinforce and Correct – essentially mean “give feedback”. So, when you are done with the Teach segment (microskill #3), simply transition to S-FED: “How do you think you did managing that cardiac arrest?”, and keep going from there.
The final bedside teaching construct could look something like this:
- Get a commitment
- probe for Evidence
- self assesment
How ’bout we call it: GETs FED?
I’d love to hear your thoughts on S-FED, GETsFED, and on any other ways you’ve found to give both positive and negative feedback without “ruining the moment.” Leave your comments below.
For further reading, check out the following resources:
- ALiEM Feedback PV Card
- ALiEM Feedback Methods Overview
- ALiEM Review of Coaching in EM (LeBlanc and Sherbino, CJEM 2010)
- ALiEM Review of Feedback in the ED (Yarris et al, Acad EM 2009)
- Bell, H. Encouragement: Giving “Heart” to Our Learners in a Competency Based Education Model. Fam Med 2007;39(1):13-5.
- Neher and Stevens. The One-minute Preceptor: Shaping the Teaching Conversation. Fam Med 2003;35(6):391-3.
I opened Facebook the other day to a post that, at first glance, appeared to be a self written obituary: “I, Anne Kastor, died on July 5th of Ovarian Cancer at age 49.” Though I never knew her to be particularly active on Facebook, it seemed like something she might write. Perhaps an act of activism in the name of cancer awareness? Clicking the link I was driven to tears as I read that she was the one who had, in fact, succumbed to ovarian cancer at such a tragically young age. The “I” was nothing more than a Facebook formatting quirk.
Some way to find out.
Dr. Kastor was a primary care physican and a faculty member of the SUNY Downstate College of Medicine. Of the four years I spent at Downstate, Anne and I interacted for only three. But that short period has had a lasting personal and professional impact on me.
In 2006 I was a member of a group of Downstate students that organized around the idea of opening the first student-run free medical clinic in Brooklyn, NY. We kind of knew what we wanted to do, but we didn’t have a plan. We also knew that students couldn’t open a clinic alone. A physician and faculty champion was needed. Asking around, it became obvious that Anne was exactly the person for us. She had a reputation for caring deeply about her patients (imagine that) and for being a passionate advocate for universal access to health care. As her obituary said, she was a “life-long advocate for justice.” (See also this 2010 news item from Cornell)
No other names even came up. Downstate is a large medical school that is part of an even larger inner city medical center. But still, every single person we asked – medical students, faculty, and administration – referred us to Dr. Anne Kastor.
The beginning was tough. We couldn’t reach her. She couldn’t find us. Multiple emails and phone calls, appointments that had to be postponed, scheduling conflicts. Then, at some point, it just clicked. When we finally got together for the first time, I knew she was perfect. Anne was blunt and compassionate, and obviously had no patience for the B.S. politicking that public institutions are notorious for. That said, she also understood how the system worked, and knew how to work it to her advantage.
Anne met with the group regularly, and from the first moment she insisted we call her by her first name, not Dr. Kastor. She was the first physician I have ever known by their first name. This may not seem meaningful to some, but in such a formal environment it was like a beacon of compassion and practicality. We all complied, of course. All of us, that is, except HL (who I hope will read this) who, for three years, insisted on calling her Dr. Kastor, despite his own generally casual personality. I think this was driven by a deep respect and admiration that we all felt for her.
She always made herself available to us, arranged for meetings with hospital leadership, and generously gave from her wisdom. She gave us the freedom to explore all of our ideas while keeping close tabs on our work, and she never hesitated to rein in the group when our visions for the clinic bordered on delusional. Then, when the Brooklyn Free Clinic (BFC) finally opened its doors after 18 months of hard work, she become its first, and for several months its only, preceptor. That’s when all the other volunteers finally also got to experience the amazing teacher and compassionate physician that she was.
Anne was key to the development of the BFC. I know there was much more to her than this simple, minor act. But this is how we knew her. She was an amazing mentor to the leadership group. She was an inspiring clinician to all of the volunteers. And she reminded us that primary care is not dead. Even in this difficult practice environment, Dr. Kastor showed us, and taught us, the essential role that the primary care physician plays in her or his patients’ lives.
Her approach to medical care was hard-wired into the BFC’s operations manual and lives on in the generations of students who have grown in to physicians under her care, and in the weekly clinic sessions that continue to provide comprehensive, high-quality medical care to the uninsured in Brooklyn.
Thank you, Anne. I will miss you. We will all remember you.
(And sorry, Anne, I imagine you might have found this a little too sentimental)