Ditching the Feedback Oreo

Revisiting Precepting 101 Advice - Part 1: Ditching the Feedback Oreo

 Most of my remediation coaching referrals arrive to me via email in the form of an evaluation. "See attached. Are you willing to take on this student? It sounds like another challenging one. Do you have time for this?" I haven't turned down a request yet. Challenging cases are my favorite!

 Reading these evaluations can be heartbreaking at times. The dysfunctional preceptor-student relationship becomes quickly obvious. I can read what the preceptor isn’t saying: “I wasn’t prepared to manage a student who needed more than I can give.” “I don’t know how to help this student.” “Precepting is hard and time consuming – I don’t have time for students who aren’t ready for my rotation.” Many preceptors who must fail a student often find the ordeal emotionally and professionally draining. I know this from personal experience.

 I have worked with hundreds of students on the receiving end of these evaluations. No student starts a rotation hoping to struggle or fail, and it’s natural for them to look for external reasons to blame for their poor performance. So, I’m not surprised when students become defensive about feedback and resistant to owning their mistakes during the rotation. I’ve come to learn many students feel embarrassed by their performance or even feel shame for disappointing others. In addition, if the evaluation is not clear on how to improve, students may feel overwhelmed or lost, unsure of what to change to avoid a repeat failing performance. Therefore, they may lose the self-confidence needed to perform well in subsequent rotations. Even as a seasoned remediation coach, I find it challenging to help a student decipher a negative review, but over the years I've been able to help students recognize what they should pay attention to, what to ignore, and what to be grateful for in the evaluation.

What makes feedback effective – and what doesn’t?

As a new practitioner, I was trained to give feedback to students via the Oreo sandwich method (good-bad-good). I’ve seen the Oreo method mentioned in numerous leadership and preceptor development programs over the years. I personally lost my belief in the feedback Oreo when I realized preceptors were oversimplifying it, often just sugar-coating negative feedback to the point students didn’t hear what was most needed to improve. Oreo feedback encourages preceptors to consider is the feedback polarity – good versus bad – which has little relationship to effective feedback. Instead of the Oreo, I incorporate three essential ingredients into all my feedback: Observation, Relevance, and Goals. These ingredients can really elevate feedback, as well as transform negative feedback into actionable constructive guidance.

 Example of ineffective feedback:

“You’re great with patients and are comfortable educating them. But, you take too long with each case and need to see more patients daily. You do a thorough job working up the patients before you see them.” (Classic Oreo feedback: positive -negative – positive)

Examples of effective feedback:

"You're currently able to manage a patient roster of 4 cases per day (Observation), but successful practitioners in this setting must be able to manage at least 8 per day (Relevance). The goal for the remainder of the rotation is to improve efficiency without sacrificing quality of work and working towards managing 8 patients daily (Goal)."

 "You've consistently managed a panel of 12-15 patients daily for the past two weeks (Observation). This is impressive as we only expect students to manage 8 patients daily (Relevance). By seeing more patients, you've become more efficient and independent, and we've had more time to talk about cases (Achieved Goal). Keep up the good work!"

If your feedback is missing one of the three vital ingredients, then seek some peer review of the feedback and evaluations you’re submitting to learners. Be extra aware of simple observations or criticisms that do not create awareness, clarity, or growth. Practice this approach when giving successful learners good feedback. When it comes time to use this for a struggling learner, you can avoid the trap of ineffective feedback.

 Students ask, "How badly am I doing, really?"

 When debriefing bad evaluations with students, I find many students struggle to understand how worried they should be about their deficiencies. To help them understand feedback, I give students a framework I call “The 3Cs” to label negative feedback: Constructive Feedback (Helpful to know), Critical Feedback (Important to know and address), and Catastrophic Feedback (Indicating Failure). For the student who is passing but is unaccustomed to detailed or critical feedback, this exercise can help students keep their anxieties about feedback in check. For students who are failing, this exercise provides a tool to digest the feedback and distinguish between helpful and unhelpful feedback. This also provides an opportunity to empathize with students. Students may shut down and withdraw if they feel success is out of reach.

 I also challenge students to look past unhelpful feedback. This is feedback that lacks clarity, context, or is overly emotional. When a learner fails, preceptors may also feel the weight of failing the learner entrusted to them. Preceptors may feel frustrated, set-up for failure, unsupported, and feel the need to withdraw from precepting in order to protect their practice and patients. These emotions can make their way into learner evaluations, which can be difficult for students to look past. It can be hard to defend a preceptor's evaluation when the preceptor is not being clear or there is too much criticism and emotion in an evaluation.

Preceptors ask, "Why isn't my student improving?"

Nothing frustrates a preceptor more than a student who doesn’t improve after being given “feedback,” so it is important to make sure feedback is clear and understood by the learner. For preceptors needing to document a failing performance, I recommend adopting the 3Cs. Preceptors need to be intentional about ensuring they are communicating their level of concern about a learner’s abilities. Avoid making constructive feedback sound devastating - this usually just comes across as being mean and unhelpful. Likewise, concerns about deficiencies preventing a passing grade should not be obscured or softened, as this sends a mixed message. The greater the concern a preceptor has, the greater the need for clear feedback.

Below are examples of feedback about the same student performing the same skill in a rotation, but from different members of the precepting team. Can you identify which statement is constructive, which is critical, and which should be viewed as catastrophic for the student's ability to succeed in the rotation? Which statement is simply unhelpful?

Preceptor A: Ben needs to work more efficiently and ensure patient notes are up-to-date and timely entered into the chart. I've noticed occasions when Ben's notes are not in the chart prior to the next appointment, which hampers the ability of whoever is seeing the patient next to have a clear understanding of the treatment plan. Ben should slow down when charting and double check his work. I expect him to improve this skill in the remainder of the rotation.

Preceptor B: Ben mixed up two patients and placed incorrect patient information into a chart. We showed Ben the chart system and told him to never mix up patient information, but he did it anyway!

 Preceptor C: Ben has made several charting errors despite coaching and bringing these errors to his attention. A few errors resulted in confusion in the treatment plan that could put the patient at risk. If Ben continues to make these errors or does not improve significantly, he will not be allowed to continue to document in the chart, which is a skill we expect all students to perform successfully in order to pass this rotation.

 Preceptor D: Ben is doing well overall, but he has had some mix-ups in the charts. We've pointed them out. He needs to continue to double check his work to avoid errors.

Notice the mix-messages across the preceptors in addressing the same problem? Is Preceptor A telling Ben to slow down or speed up? Is Ben at risk of failing (Preceptor C) or does he simply have room for improvement (Preceptor D)? And with the lack of clear goals from Preceptor B, what should Ben do differently to meet their expectations?

In short, use the Observation - Relevance - Goal framework to ensure clear feedback is given. Assess for tone using the 3C’s to ensure you’re communicating the right degree of concern to the learner. Now, you can save the real Oreos for an end-of-rotation celebration!