Ihave recently begun teaching. Communication skills teaching: the challenge of giving effective feedback. Communication skills

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1 Communication skills Communication skills teaching: the challenge of giving effective Sally Quilligan Clinical and Communications Skills Unit, University of Cambridge, UK Effective is complex Ihave recently begun teaching facilitators how to teach communication skills, and the experience has reminded me just how difficult it is to give effective. In 2005, Henderson et al. 1 highlighted that the ability to give and receive effective is a life-long skill; and one that all doctors need to develop if they are to engage in reflective practice. Effective is complex. It involves someone s thoughts on another person s performance that are delivered in a form that enables the recipient to listen to what is being said, receive it constructively, reflect on what has been said and consider how to take action as a result. 1 Within communication skills teaching, the role of the facilitator in managing is made even more complex: as well as being provided by the facilitator, may be given by the group of students as a whole, the participant role-player or actor, or the patient. My own experience has taught me that poor that is judgemental or simply poorly thought through may well have a negative influence on the ability of students to engage effectively in future experiential sessions and with reflective practice. But effective, non-judgemental can help learners to develop an awareness of their strengths and of areas that need work. It is then perhaps not surprising that, when running courses for teachers on communication skills teaching, the issue of how to give effective is frequently cited on participants agendas as their greatest need. One reason for this may be that 100 Ó Blackwell Publishing Ltd THE CLINICAL TEACHER 2007; 4:

2 learning communication skills is different from learning examination or practical skills, and potentially much more threatening. Box 1. Giving effectively when teaching medical interviewing Giving effective involves: establishing an appropriate interpersonal climate establishing mutually-agreed goals relating to the learner s agenda, not the teacher s eliciting the learner s thoughts and feelings reflecting on observed behaviours being non-judgemental relating to specific behaviours offering the right amount of getting the learner and/or the group to offer suggestions for improvement giving well-timed and allowing the learner the opportunity to try again principles, designed to maximise both learning and safety in experimental sessions, are summarised in Box 1. There has been debate about whether the order of is important for group safety, 3 and whether one should start with positive comment or focus initially on the learner s agenda and ensure balanced by the end as in agenda-led outcome-based analysis (ALOBA). 2 From my experience as a facilitator and teacher, three key points stand out: must be descriptive; comments about what is working and things that could be improved need to be supported; and the way is given is more important than what is said. Communication skills are neither intrinsically good nor bad; they are simply helpful or not helpful in achieving a particular objective in a given situation. 2 Phrases such as I thought that was harsh or You seemed uncaring are judgemental and likely to create defensiveness. Implicit within such statements is the suggestion that the student carrying out the interview is being compared against some agreed standard, and the student has failed. assimilate. It still identifies the problem, but in a way that is not seen as a deficiency in the learner. 2 Descriptive given in this way also ensures that the comments are backed up by discussion about what was observed. In this way, learners are not given advice; instead, there is a sharing of experiences and observations, and discussion follows about the objective, and other ways in which it might be achieved. Box 2. Why giving effective is difficult Feedback needs to address learners individual needs It is very hard to get the balance right Feedback needs to be limited to the amount of information a learner can use, rather than what the facilitator might want to give It is difficult to know when to give Providing descriptive is challenging The facilitator needs to maximise the benefit that can be gained from the actor s Feedback needs to be focused on the objective HOW TO GIVE FEEDBACK Much has been written about how to give, 2 4. The The example in Box 3 shows descriptive, non-judgemental linked to outcome, which is easier for the learner to When giving it is important always to start with the learner, and to ensure that focuses on the learner s agenda, not the teacher s. 2 On finishing the role play, a student needs a moment to think about what has just taken place, and then be encouraged by the facilitator to offer his or her own assessment. This enables the facilitator to see immediately the student s insight into what happened in the role play, and to direct to meet the student s agenda. The facilitator can then ask either the actor or the group to comment on the points the student has raised. Ó Blackwell Publishing Ltd THE CLINICAL TEACHER 2007; 4:

3 Box 3. An example of descriptive, non-judgemental linked to outcome You asked us to look out for whether you were empathic. I noticed when she said her father died of cancer her voice quivered a bit, and then that your facial expression remained the same, and you then asked her if there was any other history of cancer in the family. Did you notice that yourself? It is very hard to get the balance right Providing constructive that includes discussion about what is working and what areas need improvement is not easy. Students want constructive and often ask facilitators not to be too kind, but must be balanced to be effective. Many teachers have not had good role models themselves with regard to giving constructive, and so feel much more comfortable staying in the realm of positive rather than addressing areas that might need work. Alternatively, some facilitators find, particularly when a student focuses on his or her own weaknesses, that they discuss only the points that the student raises and fail to highlight the behaviours that worked well. In addition, the facilitator needs to be acutely aware of all the the student has received from the actor and the group, and ensure that their own balances what has already been said. Many teachers have not had good role models SO WHY IS GIVING EFFECTIVE FEEDBACK DIFFICULT? Box 2 lists the reasons why giving effective is difficult. These are discussed in detail below. Feedback needs to address students individual needs Sometimes it s difficult to give that addresses the needs of individual students. If a learner is to be enabled to work to his or her own agenda, needs to be focused on the objective that the learner has identified. However, this might not happen, for a number of reasons. First, because the learner s objectives have not been teased out before work begins with the actor, 2 or the learner is unable to voice them. Second, while working with the actor, the learner s objectives might change, but this might not be made explicit. And third, because even when clear objectives are established, does not consider the learner s objectives. Feedback needs to be limited to the amount of information a student can use rather than what the facilitator might want to give The amount of given has also to be tailored to the needs of individual students; some learners will only be able to cope with a couple of points to work on, while others will be receptive to much more. It is sometimes helpful to highlight effective skills a student has used occasionally, and then frame in terms of the skills that could be used more often: I thought when you summarised the patient s symptoms you clearly showed the patient you were listening, and that helped you to structure the start of the consultation. What do you 102 Ó Blackwell Publishing Ltd THE CLINICAL TEACHER 2007; 4:

4 think the effect would have been if you had done that when you moved on to discuss management? It is difficult to know when to give The student or the facilitator can stop a role play at any point, but knowing when to do this can be difficult. Although there will always be time constraints, it is helpful before stopping a student to reflect on whether sufficient opportunity has been provided to meet his or her objectives. It is also important to explain to the student why the role play has been stopped at that point. In addition, doesn t always have to be given at the end of a student s session with the actor. Sometimes it is helpful to give midway, explore other ways in which the student could achieve his or her objective, and then allow time to rehearse the new strategy to see if it works better. This process is shown in the example in Box 4. Providing descriptive is challenging Feedback that is not descriptive may be personal and judgemental, neither of which are helpful and may leave students feeling demoralised and deskilled. Feedback also needs to be specific rather than generalised. It is so much easier to give general, nonspecific evaluative comments: You were really good or I m not sure the patient understood you. To be able to give effective requires a lot of effort and concentration. Both facilitator and the student group should take notes during the patient encounter to capture specific phrases used by the learner that were particularly effective. If you want to be able to describe exactly what you saw, and why something worked or didn t, you need to observe the situation closely. The facilitator may well need to guide and engage the students: Well, OK, let s get some. What do people think about what has gone on so far? What have you observed? Sometimes a learner will give a general description, and the facilitator will need to focus the in more detail, as in the example given in Box 5, where the student was working with a depressed patient. One final challenge is to make sure the consequences of the given are checked. Facilitators need to be very conscious of a recipient s verbal and non-verbal reactions, and check out the response overtly. In turn, the recipient should check whether he or she has understood the correctly: What I think you mean is. This prevents distortion and misunderstanding, which so easily occur if there is even a hint of defensiveness. 2 The facilitator needs to maximise the benefit that can be gained from the actor s The facilitator needs to work closely with the actor, and the actor needs to be in tune with the focus of the teaching. The actor needs to provide directly to the student, still in role but in neutral mode that is, without any emotional overtones. This ensures that the actor is able to describe, in a way that is supportive to the student, how he or she felt in the role of the patient. Actors have commented that it is helpful if the facilitator can forewarn them when they are about to be asked for, and to indicate which aspect of the role play the facilitator is asking them to address. This gives the actor time to think, and to ensure that Sometimes it is helpful to give midway Box 4. Giving at the right moment can be a challenge A student is interviewing an actor role playing an elderly client. The facilitator perceives that the student is struggling and takes time out to give the him support and help him to explore the problem. Facilitator: OK... let s stop there for a moment. Are you all right? Student: No. I feel like we re going round in circles. Facilitator: Can you give me an example? Student: Well, he keeps talking about his wife. I m trying to find about how he copes at home and he he just doesn t seem to want to talk about things I need to discuss I feel like I m losing control. Facilitator: Yes, I ve noticed he s mentioned his wife three times now. Do you know what you said the last couple of times? Student: No. Facilitator: You asked him Can you get around OK?, and he said Well, I have to get tea for my wife, and you said Do you have stairs? [Facilitator asks group what they ve observed and whether they have any suggestions.] Facilitator: So what James [group member] is suggesting is that perhaps he needs to talk about his wife, and that you might well get more information about his mobility from this. Then once his concern has been addressed, he might be able to focus on other things Student: I suppose if he s worried about caring for his wife it might help to discuss it. Facilitator: Would you like to give that a go? Ó Blackwell Publishing Ltd THE CLINICAL TEACHER 2007; 4:

5 Box 5. Focusing the Student: I felt the patient was detaching herself Facilitator: What made you think that? Student: She lost eye contact and sank down in the chair. Facilitator: Yes, I noticed that happened when you asked had she been thinking about it for a long time, was it planned? Shall we ask the patient how she was feeling? Box 6. Forewarning the actor about OK, Peter, so you are wondering if expressing your concern non-verbally was enough to convey your concern to Miss Peto we ll ask her in just a second, but what does the research suggest to us about expressing empathy verbally and non-verbally? Every doctor is a teacher focuses on both the student s identified objective and the aspect highlighted by the facilitator (see Box 6). The next challenge: to help patients give effective Patients are keen to share their expertise and understanding of their illnesses and how these make them feel. 5 Currently, few opportunities exist for student doctors to receive from their patients about their interviewing skills. 6 We try to get our introductory course students to ask for from patients about their medical interviewing skills. At the end of an interview the student tells the patient that they are just starting to learn about how to talk to patients, and ask if the patient would like to give them any advice. Students tell us that the patients usually reply by making an evaluative statement such as Oh, you were lovely. It has always been assumed that patients would not feel able to say more, or certainly would not want to give constructive criticism for fear of upsetting the student and potentially affecting their quality of care. It could also be that patients do not know how to give effective, and if this is the case, could we give them more information to enable them to describe the skills they saw the student use? Perhaps facilitators should mirror the technique used in the classroom, and ask the student to say at the start of the interview what help they would like from the patient. One interesting study, by O Keefe and Whitham (2005), showed that parents of paediatric patients were able to give useful, and it benefited the medical students to receive these evaluations of their paediatric interview skills. 7 However, this study did not use face-to-face. Clearly, this area of involving patients in providing is ripe for research. CONCLUSION Every doctor is a teacher 8 and will at some time be required to give students or colleagues on their performance. Within clinical communications skills teaching, it is the facilitator s responsibility to ensure that effective is given to students by the group, the actor and the facilitator him/herself. This requires the facilitator to help students identify what they want to work on, and then to ensure that any given is timely, balanced, articulated clearly in descriptive terms, and helps students to work out what the problems are and consider other approaches. The key learning points are listed in Box 7. It is not surprising that providing effective is such a challenge. The next challenge may well be to encourage patients to give effective too. 104 Ó Blackwell Publishing Ltd THE CLINICAL TEACHER 2007; 4:

6 Box 7. Key learning points Feedback should help the learner to identify any problems Feedback can come from other students, the actor, the facilitator, or from patients Feedback needs to be both specific and descriptive Feedback is about sharing information about what is observed and not about giving advice Feedback should be solicited and not imposed Feedback needs to be balanced and constructive REFERENCES 1. Henderson P, Ferguson Smith A, Johnson M. Developing essential professional skills: a framework for teaching and learning about. BMC Med Educ 2005;5: Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine, 2nd edn. Oxford: Radcliffe Publishing, Pendleton D, Schofield T, Tate P, Havelock P. The new consultation. Oxford: Oxford University Press, Stewart M, Brown J, Weston W, McWhinney I, McWilliam C, Freeman T. Patient-centered medicine: transforming the clinical method. Oxford: Radcliffe Medical Press, Department of Health. The expert patient: a new approach to chronic disease management for the 21st century. London: Department of Health, Egener B, Cole-Kelly K. Satisfying the patient, but failing the test. Acad Med 2004;79: O Keefe M, Whitham J. Early identification of at risk students by the parents of paediatric patients. Med Educ 2005;39: General Medical Council. Tomorrow s doctors: recommendations on undergraduate medical education. London: GMC, 1993 (revd 2002). Ó Blackwell Publishing Ltd THE CLINICAL TEACHER 2007; 4:

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