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.