Practice Perfect 787
Improve Feedback Enhanced Teaching - Break It Down

One of the challenges of being a teacher of any sort, whether for students or residents, is providing feedback. Now, it’s easy to give negative feedback (“You’re a terrible doctor, Shapiro!”), but what I’m talking about is truly educational feedback. We know that our resident trainees desire feedback at the time of their experiences1, but let’s focus more specifically on a method to help trainers to frame the feedback they give.

Let’s first list a few important characteristics of high-quality feedback which is…

  1. Immediate – The closer in time to the event, the fresher will be the experience for the learner. This also decreases ambiguity due to forgetting what occurred.
  2. Constructive – The feedback should be aimed at helping the learner improve in a safe and respectful environment.
  3. Specific – Comments should be as concrete and focused as possible. Vague comments don’t support learning.
  4. Actionable – The learner should be able to do something with the criticism provided with the primary goal being doing the skill under discussion correctly and competently in the future.

The hardest part of this for most of us is making the feedback specific enough to help trainees understand what they’re doing incorrectly and changing future behavior. My suggestion to make this process just a little easier is to break it down.

Break It Down

Breaking down an activity with the intent to give feedback is a way for a preceptor to prepare for an upcoming situation with a trainee. This exercise is actually very simple but does take some mental work ahead of time. For every task we execute or skill we acquire, a number of smaller, more elementary subskills combine together to make that primary skill happen successfully. The more complex the skill, the larger the number of subskills.

In general, an educator would Break It Down using the following steps.

  • Step 1: Determine the skill to be evaluated.
  • Step 2: Break that skill down into its component parts
  • Step 3: Consider what prior knowledge, if any, is necessary to do that skill.
  • Step 4: Watch the trainee do the skill. Observe the occurrence of each subskill as it happens looking for errors.
  • Step 5: Give specific feedback using the learner’s correct/incorrect execution of each subskill as a guide.

Let’s take surgical soft tissue dissection as an example. The surgeon is scheduled to do a bunionectomy procedure with a new first year resident. She wants the resident to prove his ability to do a proper superficial dissection (Step 1) before moving on to dissection of the joint itself. Before the procedure, she breaks this skill down into its most basic parts (Step 2) which variably include choosing a scalpel size, properly holding the scalpel, pulling the scalpel across the skin using the correct part of the scalpel in a controlled depth incision, using the electrocautery or hand-tying blood vessels, and spreading the subcutaneous layer in the proper manner with the correct instrument. She plans to ask the resident what anatomical structures are at risk (Step 3), expecting the resident to know the anatomy, surgical instrument names, and where to mark the planned incision. She then watches the resident make the incision and perform the dissection (Step 4), watching to make sure the resident doesn’t do anything that will harm the patient. She may then choose to provide intraoperative feedback (Step 5) or wait until the end of the procedure to discuss what the resident did correctly and incorrectly keeping those subskills in mind. For example, if the resident started to tip his hand so the scalpel was no longer 90 degrees to the skin, the attending would stop him and explain how to properly to do this.

As a teacher, there’s one other step to this process (Step 6) which is to expect improvement of that skill at the next encounter. It is absolutely permissible for an attending to tell their trainee, “Now that we’ve reviewed and discussed these skills, I expect that you will show me how much you’ve improved during our next case together by doing what we discussed today correctly.”
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I picked a surgical topic, but this is applicable for all skills from trimming calluses to managing a busy podiatry clinic. My description looks long, but this is actually a very quick process once a trainer practices it a few times. Give it a try and see how much more specific and useful your feedback becomes.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
  1. Shofler D, Chuang T, Argade N. The residency training experience in podiatric medicine and surgery. J Foot Ankle Surg. Jul-Aug 2015;54(4):607-614.
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