Improving Clinical Feedback after Transitions of Care

Tammy Ruth
Seattle Children's Hospital

Background: Transitions of patient care often occur before the final diagnosis or outcome is known; physicians follow-up when motivated by curiosity or personal connection and when time allows, without a widely used platform to facilitate learning or to capture patients who experience clinical worsening.

Aims: This quantitative study describes the impact of an automated provider email sent after a patient returns to the ED within 72 hours and is subsequently admitted to an inpatient service. We determined the usefulness of this intervention by identifying (1) the actions taken by the recipient of an email, (2) the rationale for these actions, and (3) their preferences for receiving this type of clinical feedback. 

Methods: We conducted an online cross-sectional survey of a convenience sample comprised of 131 pediatric residents, pediatric emergency medicine fellows and attendings at a large, single-site, west coast academic children’s hospital. 

Results: Overall response rate was 47%. Residents (100%), fellows (100%), and attendings (95.65%) read the email, with 45.65% indicating the email prompted them to do something different from how they typically follow-up on ED patients. Respondents spent additional time reflecting (84.78%), reviewed the patient’s electronic medical record (73.91%), read more about the patient’s condition (30.43%), discussed the patient’s case with someone else (26.09%), and made changes to their practice (21.74%). For this type of clinical feedback, 82.22% preferred to continue to the current notification system.

Conclusions: Residents, fellows, and attendings find this system educationally helpful for clinical feedback after patient transitions and report changes to their medical practice following the receipt of an automated email. 

Qualitative Analysis of Feedback in Primary Care Resident Clinic

Shelley Ost

UT Methodist Physicians

Background: Residents spend a great deal of time with supervising faculty in their continuity clinic in primary care residencies. The long-term relationship between the resident and faculty presents an opportunity for providing feedback on the resident’s knowledge, skills, and practice style. 

Methods: Focus group discussions with primary care residency supervising faculty at the University of Tennessee Health Science Center were analyzed to determine the goals, current knowledge and feelings, and barriers regarding providing feedback to residents during continuity clinic. Qualitative analysis using grounded theory was performed to identify themes within the focus group data, leading to an underlying theory about the provision of feedback to residents in primary care resident clinic. Data were used to propose improvements to the current process of feedback.

Results: Categories in the data included the longitudinal nature of the faculty-resident relationship, need for management of emotional response to feedback, faculty preparedness, and difficulty determining the content of feedback that should be provided. These influenced the three major components of feedback, which were the content, delivery, and reception of feedback.

Conclusion: Addressing components of the content of feedback, delivery of feedback, and the attitude or receptivity of the learner can help improve the quality and quantity of feedback given to residents in clinic.

Simulation Based Mastery Learning Improves the Performance of Donning and Doffing of Personal Protective Equipment by Medical Students

Danielle Miller

Stanford University School of Medicine

Introduction: Medical students lack adequate training on how to correctly don and doff personal protective equipment (PPE). Simulation-based mastery learning (SBML) is an effective technique for procedural education. The aim of this study is to determine if SBML improves proper PPE donning and doffing by medical students.

 

Methods: This was a prospective, pretest-post-test study of 155 medical students on demonstration of correct PPE use before and after a SBML intervention.  Subjects completed standard hospital training by viewing a CDC training video on proper PPE use prior to the intervention. They then participated in a SBML training session that included baseline testing, deliberate practice with expert feedback, and post-testing until mastery was achieved. Students were assessed using a previously developed 21-item checklist on donning and doffing PPE with a minimum passing standard (MPS) of 21/21 items. Differences between pretest and post-test scores were analyzed using paired t-tests. Students at preclinical and clinical levels of training were compared with an independent t-test. 

Results: Two participants (1.3%) met the MPS on pretest. Of the remaining 153 subjects who participated in the intervention, 151 (98.7%) reached mastery. Comparison of mean scores from pretest to final post-test significantly improved from an average raw score of 12.55/21 (standard deviation [SD] = 2.86), to 21/21(SD = 0), t(150) =36.3, p<0.001. There was no difference between pretest scores of preclinical and clinical students.  

Conclusion: SBML improves medical student performance in PPE donning and doffing in a simulated environment. This approach standardizes PPE training for students in advance of clinical experiences.

Active Learning in CME: Creation of an objective observation tool

Yemisi Jones
Cincinnati Children's Hospital


Introduction: Despite the evidence supporting the use of active learning strategies to enhance learning, they are infrequently used during continuing education (CE) lectures, in both in-person and virtual settings. Studies of active learning during didactic sessions have predominantly involved novice learners who require more intensive active learning strategies. This project aims to create an observation tool for use in program evaluation.

Methods: We reviewed the literature for active learning techniques described in large-group medical education. These strategies were then rated by 2 separate Delphi panels, one made of medical education experts (n = 9) and one of CE learners (n = 12). Each panel completed two rounds of ratings in an effort to achieve consensus. Experts were asked to rate each strategy for appropriateness and feasibility for both in-person and virtual session use. Attendees rated each strategy for likelihood to engage in an in-person and virtual format. The results of the Delphi panel informed which strategies were included in the Observed Active Learning Tool (OALT). Further validity evidence for the tool was collected by assessing inter-rater reliability using Fleiss’ kappa of four raters (2 clinicians and 2 non-clinicians). Iterative adjustments were made to the tool to achieve optimal reliability.

Results: The panels rated 31 active learning strategies and found the majority (25) to be appropriate and feasible for in-person (27) and virtual (25) CE large-groups. The attendee panel reached consensus on high likelihood to engage with 18 strategies in both in-person and virtual settings. There were 20 strategies which reached positive consensus with both groups and none which were rated poorly by both panels. Initial inter-rater reliability of the tool was moderate (kappa .53-.63). After modifications to the tool, final kappa was ***.

Discussion: Experts and CE attendees rated highly most of the active learning strategies from the literature for both virtual and in-person learning environments. The list of strategies rated highly by both panels can serve as a guide for CE planners and educators seeking to incorporate active learning into large-group learning. In addition the OALT may be used by both clinical and non-clinical CE professionals to guide program evaluation and improvement.

Perceptions of Feedback Delivery by Surgical Educators in the Era of Gender Diversity Awareness

Michelle Clarke
Mayo Clinic


Background: The primary goal of authentic feedback is to improve a learner’s future performance by providing accurate, actionable, and constructive critiques of performance. Unfortunately, quality of feedback is known to be influenced by gender. Recent societal and institutional commitments to diversity, inclusion, and equity may also influence the feedback process. This study explored the perceptions of experienced anesthesia and surgical educators of providing authentic feedback, including the impact of gender.

Methods: Eleven semi-structured interviews were conducted with faculty in anesthesia and surgical subspecialties. Open-ended questions probed the climate of feedback, the participant’s current feedback processes, barriers to authentic feedback, and the perceived ability to provide authentic feedback to minority trainees. The Braun and Clarke method of thematic analysis was employed, and a narrative composed proceeding from description to interpretation to explanation.

Results: The major barrier to feedback identified was the trainee’s real or anticipated negative reactions to corrective feedback, which was independent of gender. Participants perceived a reduction in authentic feedback due to fear of trainee reprisals. Individuals in departments with greater gender parity or who had higher formal education roles were more facile and confident in providing corrective feedback. Participants felt that educating faculty on feedback delivery and trainees on feedback reception would be valuable.

Conclusions: Faculty perceived that the biggest barrier to corrective feedback was the anticipated or real reaction of the trainee. While gender likely plays a role in feedback delivery, this was not the primary driver of inauthentic feedback.