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Tips for helping trainees learn—without intimidation

From the June 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Maureen Glabman

SAN DIEGO—Instructors who use criticism and intimidation in teaching residents may think they're part of a long tradition in medicine, but they're not really helping their trainees or their patients.

At an Annual Session presentation on clinical teaching, S. Ray Mitchell, FACP, program director and associate professor of medicine and pediatrics at Georgetown University in Washington, said that being overly critical of trainees backfires and produces so much stress that learning is negatively affected. Teachers need to offer constructive feedback in a manner that encourages students, instead of making them defensive, he said.

When trainers offer criticism only, he said, students protect themselves by disparaging the teacher, by regarding the issue as irrelevant or by attributing the criticism to a difference in style. Worse yet, these self-protection mechanisms can sometimes extend beyond training into clinical practice and affect patient care.

At the presentation, speakers said that the key to teaching is providing regular feedback that responds to behavior, not personality. "Calling someone stupid is different from saying what they did was incorrect," said Richard J. Simons, FACP, program director of internal medicine at Pennsylvania State University College of Medicine in Hershey, Pa., who also spoke at the presentation.

The experts agreed that whether the instructor is a seasoned attending physician or a chief resident learning how to teach, the goal should be to provide enough feedback to help trainees without putting them on the defensive. Feedback is invaluable because it offers insight into trainees' actions and the consequences of their actions, providing impetus for change. An important distinction, the experts say, is that unlike evaluation, feedback presents information and not judgment.

Being constructive

Some instructors don't give enough useful feedback to trainees because they're afraid of hurting feelings or becoming less popular. But for feedback to be valuable, experts say, it must be frequent, and both negative and positive comments must be included. Plus, all parts of a trainee's job should be subject to feedback, including case presentations, history and physicals, progress notes and patient exchanges.

It also helps to be specific. Saying "your diagnosis is inadequate" is not as useful as saying, "your diagnosis did not include the possibility of influenza," according to Dr. Mitchell. It also helps to find residents doing something noteworthy, such as giving precise answers, and offer praise.

Conversely, if a student is doing something wrong, teachers must draw attention to it, but in a subtle way. "When you give negative feedback," Dr. Mitchell said, "ask the learner for their opinion and their plan for the future." While it is difficult to tell students that their differential diagnoses did not include the correct disease without embarrassing them, it must still be brought to the students' attention.

Instructors should remember that most residents are worried about being publicly humiliated. One way to diffuse that fear is by mentioning in advance, "You're going to make mistakes and not every one does this particular procedure correctly," Dr. Mitchell said.

But Dr. Mitchell warned that the danger of providing too much negative feedback is that sensitive people feel like they're being run into the ground. "Students have to feel safe to learn," Dr. Mitchell said. "You can devastate someone and it can get personal."

Levity works to diffuse tense situations. "That's why it's a three-year program," he said, to let students know they are expected to slip up.

While there are distinct hazards of giving too much negative feedback, it is possible to give too much positive feedback. Some students may find overt praise embarrassing, which is why praise should be directed at actions, not people. Experts say that telling a student "that was a great job" is not as beneficial as saying "you performed that procedure well because ..."

Providing the right tone

Overall, inspirational mentors differ from pedantic pedagogues in that they provide a forum for collegial exchange. They generate stimulation, enthusiasm and excitement through the tone or atmosphere of the clinical teaching setting.

That setting has to be relaxed enough so students can identify and address their limitations. "Ask the learner to self-assess. How comfortable were you in putting in a central line? Then criticize it," Dr. Mitchell suggested. A student who seems unfamiliar with a subject can be asked to search the literature for an appropriate article to bring to rounds the following day. It is helpful to have the trainee paraphrase feedback because it invites discussion and questions.

One teacher believes good trainer-trainee rapport leads to improved patient care. "Information can be imparted so that you remain feeling good about yourself and realize a shared goal. It translates into better patient care because you've learned something. It's a model for interaction and relationships," Ron Ben Ari, MD, associate chairman of educational affairs at the University of Southern California, Los Angeles, said in a telephone interview.

Dr. Ben Ari warned trainers not to expect student clairvoyance. "Trainers sometimes conceal information from students in the hope students will please them by coming up with it," he said. "It shouldn't be mysterious what we want our learners to learn. We should decide what we want them to know and be happy when they tell us."


Tips for teaching

At the Annual Session presentation on clinical teaching, experts said that one effective training tools is the "One Minute Preceptor," which was created by physicians at the University of Washington at Seattle. It uses the following steps:

  • Ask for input: "What do you think is going on?"
  • Probe for supporting evidence: "What led you to that conclusion?"
  • Teach general rules: "When this happens, do this ... "
  • Reinforce what was right: "Specifically, you did an excellent job of ... "
  • Correct mistakes: "Next time this happens, try this ... "

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