Taking the Fear Out of Feedback

by Connie Yoon, Pharm.D., Assistant Professor, University of Maryland School of Pharmacy

During my two years of residency training, I knew providing feedback to my preceptors regarding the rotation and their teaching behaviors was expected.  Yet for some rotations, this moment was filled with fear.  Fear that the receiver would misunderstand my intentions or that this may harm my relationship with this person.  Fear that what I said would be misused or turned against me.  Despite this fear, I provide them with honest feedback.  Why did I take the risk and perhaps face retribution? Because feedback is necessary for professional development and learning.  I consider feedback as an opportunity for quality improvement, not a reason for retaliation.  I should also clarify that while fear may be a roadblock to giving feedback, it is also a roadblock for those receiving feedback, particularly when the feedback is negative.¹  Feedback is a two way street.  In a field where feedback is critical to facilitating education and patient care, it is important to review methods for delivering and receiving constructive feedback.

To begin, we must define feedback in the context of teaching and learning.  Feedback involves “a process to collect information to determine whether or not successful teaching and learning has occurred.”²  Feedback is “a commitment between teachers and students for academic and professional development.”³   It is an important tool used by successful teachers to make adjustments to the teaching process by identifying areas that are successful and those that require improvement.

Feedback is strongly associated with students’ perceptions of the quality of education.⁴  Therefore, as educators, we must consistently give and request feedback from students.  However, the unfortunately reality is that students are infrequently requested to provide feedback regarding the teacher’s performance (and typically only at the end of a course!).  Conversely, teachers do not provide feedback to students as often as they'd like.⁵  Moreover, teachers tend to have an inflated view of their feedback skills.  This was evident in a study published in 2008 by Sonthisombat.⁵  This study surveyed Pharm.D. students and preceptors to compare the perceptions of preceptors to that of students in regard to the preceptor’s teaching behaviors.  Survey items included rating the teacher’s frequency in giving positive feedback for good work, inviting comments or criticisms of the preceptor, discussing student strengths and limitations, and evaluating and advising students of their progress.  On nine of the 47 items, preceptors’ ratings were significantly higher than that of student ratings.  The majority of the preceptors perceived themselves as “well done and adequate” in terms of providing feedback to students, providing positive feedback, and responding positively to student’s comments and suggestions.  A significantly lower percentage of students rated their preceptors as well done and adequate in these areas, revealing a disparity between preceptors’ and students’ perceptions.  This study identified several areas for preceptor development and providing feedback was clearly a prime component. As educators, if we are committed to our students and the quality education of their education, giving constructive feedback is one thing we must learn to do well.

In order to fulfill this commitment, we must create an environment that encourages giving and receiving feedback.  There are several characteristics of constructive feedback.^1-3  Feedback should be:

• Relevant.  Address the teaching and learning performance objectives identified for the learning activity.
• Objective.  Base feedback on facts or observations not on feelings. Keep comments impersonal as much as possible.
• Individualized.  The goal of the feedback is to meet the needs of the student or teacher and enable the receiver to maximize their potential.
• Helpful or informative. Provide suggestions for improvement.
• Respectful.  Respect the student and/or teacher’s integrity and needs.
• Confidential.  Do not involve intermediaries unless absolutely necessary.  Only the student and teacher should be involved in the feedback session.
• Encouraging.  The student and teacher should be motivated by a desire to improve their learning/teaching methods.  This will can help to reduce the hostile emotions commonly associated with feedback that is negative.

In general, feedback is better received when given in a timely manner so that recipients have a opportunity to improve.  More frequent feedback makes each encounter less emotional and feedback becomes a common, routine part of the learning process.  Learning expectations for the activity should be articulated early to reduce ambiguities in performance objectives and minimize surprises during the evaluation.  Negative feedback should be balanced with motivational statements and positive feedback.  In order to maximize the potential use of feedback as a learning tool, both the deliverer and receiver of feedback should be receptive.  Solicit feedback and express appreciation when receiving it to model an accepting behavior.¹  Most importantly, create an atmosphere of trust and respect when giving and receiving feedback.

Constructive feedback, given or received, plays a critical role in teaching and learning.  We should not allow fear to prevent us from employing feedback in our daily activities.  Providing feedback in a structured, constructive manner can help minimize fear and maximize its utility as an educational tool.

REFERENCES

1.    Hunter TS. Giving and receiving constructive feedback in pharmacy practice. Drug Topics [Internet]. 2009 Jun 1 [cited 2012 Aug 30].

2.    Ovando MN. Constructive feedback: a key to successful teaching and learning. Int J Educ Management 1994;8:19-22

3.    Hamid Y and Mahmood S. Understanding constructive feedback: a commitment between teachers and students for academic and professional development. J Pak Med Assoc 2010;60(3):224-227.

4.    Torres DM, Sebastian JL and Simpson DE. Learning activities and high-quality teaching: perceptions of third-year IM clerkship students. Acad Med 2003;78:812-814.

5.    Sonthisombat P. Pharmacy student and preceptors perceptions of preceptor teaching behaviors.  Am J Pharm Educ 2008;72(5):1-7

The Instructor’s Role in Group Work

by Eun-Young Lee, Pharm.D., PGY1 Pharmacy Practice Resident, Howard County General Hospital

Teamwork is relevant to my pharmacy practice and the skills I acquired as a student in group exercises in the classroom were critical for building the habits necessary for effective teamwork. Instructors, therefore, have an important role to assist students during group exercises.

Many educators agree that group work fosters social development, critical thinking, and problem solving skills.^1,2   These skill sets are desired by many employers and can equip the students for their future career endeavors. There are several ways educators can guide students to work effectively as a team. The instructor should be actively involved in mentoring the groups while providing enough opportunities for autonomy for students to find their own resolutions and answers. Furthermore, there are several things instructors should consider when incorporating group assignments within a course.  Instructors should provide a clear purpose for each assignment and offer strategies to help address non-contributing students.

Providing a Clear Purpose of the Assignment

Instructors should help students understand the purpose of each assignment by clearly stating expectations, goals, and objectives of the group activity.^2,3,5 Identifying learning objectives assists students to focus on what needs to be accomplished.

In addition, group assignments should purposefully cultivate interdependence.  Although the instructor is available to mentor students throughout the learning process, group projects should encourage student learning amongst their peers.⁵ In other words, collaborators of a team can learn to depend on their group members. There are four types of interdependences:⁴

• Goal interdependence: By achieving one common group goal, each individual believes he or she is able to fulfill his or her own goal.
• Reward Interdependence: Good performance of the entire group leads to a reward, such as a good grade.
• Role interdependence:  Each member has a specific role and function to fulfill within the group.
• Resource interdependence: Each member has specific resources or knowledge that must be contributed.  One person does not have all the resources to complete the task independently.

Interdependence in group assignments is critical. Healthcare providers within multidisciplinary teams depend on interdependence to provide the best treatment for patients.  This requires various health care workers to coordinate and contribute knowledge according to their specialty.

Addressing Problems Related to Non-Contributing Students

Ideally, each member should equally participate, but many groups face the problem of social loafers.¹ Educators should be aware that there are two types of non-contributing students, a struggler and a social loafer. Students categorized as strugglers have difficulty participating due to a lack of knowledge or are marginally behind in their understanding.¹ Loafers on the other hand, can be characterize as “free-riders” who make little effort to contribute to the group’s work.¹

Both types of non-contributing students may be mistakenly viewed as loafers.  However, approaches to assisting loafers versus strugglers are different.  Struggling students may benefit from supplementary support from the instructor.¹ Conversely, a loafer needs a different approach. Strategies such as using peer assessments, keeping individual diaries, and retaining logs of online cooperation may be applied to monitor participation.¹ These strategies allow contributing members to successfully complete their assignment without being hindered by the slackers.¹  Social loafers should receive feedback from their group and this may correct their behavior to fully participate.¹ A downside to confronting an inactive student by the other group members may lead to the alienation of the loafer or exclusion altogether. Usually, groups are able to resolve this problem without the instructor’s intervention.¹

Instructors should define loafers and strugglers prior to assigning the project to the class.  This allows team members to identify and address the issues of loafers and strugglers differently.  Also, instructors should provide counseling to remind students that everyone in the group possess different levels of skills and contribute in different ways.¹ This allows the students to recognize that individuals who initially struggle may become highly effective participants once their skills are developed.¹ Additionally, instructors should encourage students to assign roles that best suit their expertise or skill level. Thus, I believe that allowing opportunities for all students to contribute will build confidence and allow students to thrive in group settings.

Conclusion

Group assignments offer students opportunities hands on experience to develop teamwork skills. This begins with providing groups with clear instructions to help them understand the purpose of the assignment. Inevitably, during collaborative work, members of the group may face conflicts and issues.  Instructors should utilize strategies to facilitate both contributing and non-contributing students.  This allows groups to achieve a common goal, while giving them enough autonomy to solve problems on their own.

Overall, I believe there are several advantages of incorporating group work into classroom-based courses. Being able to contribute effectively as a team member is a desirable skill employers value.  As a student, I had many opportunities and I am grateful to have worked within many groups with different dynamics.

References:

1.  Freeman L, Greenacre L. An examination of Socially Destructive Behaviors in Group Work.  The Journal of Marketing Education. 2011; 33: 5-17.

2.  Burke A. Group Work: How to Use Groups Effectively. The Journal of Effective Teaching.  2011; 11: 87-95.

3.  Group Work. Bloomington: Indiana University; 2011. [cited 2012 Sept 7].

4.  Colbeck CL, Campbell SE, Bjorklund SA.  Grouping in the Dark:  What College Students Learn from Group Projects.  The Journal of Higher Education.  2000 Jan/Feb; 71: 60-83.

5.  Atwood A, Klurfeld A, Kotker J. Using Group Work Effectively: Graduate Student Instructors Teaching and Resource Center. [Internet]. Berkley: University of Berkeley; 2012 Jan 30. [cited 2012 Sept 10].

Creativity, not conformity

by Martin Bishop, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, the Johns Hopkins Hospital

Sir Ken Robinson, an author and advisor on educational reform, has worked on educational projects in the United Kingdom since the 1980s.  He considers the traditional strategies and methods of education stifling to the creativity of children and students.¹  This lack of creativity can limit the effectiveness of graduates as they progress to their careers.  He argues the hierarchy of subjects within our formal educational systems in most countries favor mathematics, science, and languages.  This emphasis undervalues the humanities, music, or dance.  It makes sense that the modern educational system, which came to being during the rise of industrialism, would favor educational topics that provide jobs in an industrialized society (“Don’t do music, you’re not going to be a musician; don’t do art, you won’t be an artist”¹).  But creativity can be defined as more than art, dance, or musical talents.  Creativity in education can be related to the ability to solve problems and think critically by using old and familiar ideas adapted to new situations.²  By not emphasizing and fostering creativity, student learn by memorizing facts and key words to regurgitate them on a cumulative final exam.

According to Sir Robinson, “our education system has mined our minds in the way that we strip-mine the earth: for a particular commodity…and for the future, it won’t serve us.”  It is unfortunate that society values students who become physicians, lawyers, and bankers instead of appreciating a diverse arrangement of professions that suit personal interests and passions.  Moreover, the needs of the future economy of the United States (and the world) may be best met by a community of highly engaged professionals with various skills sets including firefighters, historians, artists (just to name a few).³ Robinson equates the educational system to fast food preparation or an industrial production line where curricula and assessments are standardized.³ The answer to the future of education, according to Robinson, is a personalized curriculum with external support where the student can develop at their own pace and focus on their strengths and deficits.³  There is growing support for the strategy of personalizing or individualizing instruction for students.  One example supported by Bill Gates (of Microsoft) and Eric Schmidt (of Google) is Khan Academy founded by Salman Khan.

An individualized education for each student

A traditional class consists of lectures, then homework, followed by an exam. Based on the results of the exam, the students earn a grade and the class then moves on to another topic or another subject.  If the student earns a 70% or higher, they get to move on to learn other things.  But what about the 30% (or less) of the material that was missed on the exam?  In this model, that missed material (concepts, ideas, facts) are perhaps lost forever.  In his TED presentation, Salman Khan uses an analogy of learning how to ride a bicycle to illustrate this concept.  If you are learning how to ride a bike, you might be able to mount the bike, pedal, turn, and ride in a straight line …  but perhaps you haven’t learned how to stop.  You crash into things or just fall and injure yourself all the time.  At this point, having mastered 70% of what’s expected, you would receive a passing grade and proceed on to unicycle!⁴  But you haven’t really mastered how to ride a bicycle yet!  I would occasionally ask myself about that lost knowledge during my higher education (“Well, what did I miss?”) and would often be denied the chance to review my exam so that I could learn from my mistakes.  Ideally, students should truly master each topic before moving on.

The vision of Salman Khan’s Khan Academy is to encourage each student to be accountable for his/her own learning.  He encourages student to view recorded lectures (which can be repeated as needed) at home prior to class.⁵  In this setting, students are allowed to fail without punishment or consequences, until they are able to master a specific task.  When used in conjunction with live classes, the student can access online modules and then engage in problem solving projects with their peers facilitated by an instructor.  In this setting, the instructor is acting as a mentor or coach rather than a lecturer.  For the students who are struggling with a specific task (which is shown graphically and in real-time to both student and instructor), the instructor can focus his/her effort on small cohort of students to maximize efficiency of time and effort.  Additionally, the Khan Academy uses the data (reportedly over 191 million lessons delivered)⁶ to improve modules for future students.  This software and website promise to revolutionize the way classes are taught.  The Khan Academy approach has already been implemented in classrooms in Los Altos, California.⁶  While Khan Academy has presentations and modules for primarily aimed at K through 12 student, it could be adapted to very complex topics in higher education including medicine, engineering, or history.  It is worth noting that these strategies do not foster mastery for all students.  Just as some students learn better from visual presentations or modeled behavior, only some students will fully embrace instructional video lectures.

I would aspire to bring some of these ideas and strategies to the education of pharmacy students in my present and future career.  Ideally, an approach including an element of course personalization would more effectively learn concepts.  Although a pharmacy school with a less rigid curriculum (i.e. P1 classes, then P2 classes, etc.) and increased flexibility may be years away, we should work towards this goal by making course materials available for all students in the school before and after enrollment in a course.  Although the classes and exams could still be structured in a traditional manner, at the very least lectures and exercises from the course should be open for anyone to visit or revisit.

References

1.    Sir Ken Robinson. Ken Robinson says schools kill creativity. TED: Ideas worth spreading. Published February 2006. Accessed September 20, 2012.

2.    Ferrari A, Cachia R, Punie Y. Innovation and creativity in education and training in the EU member states: fostering creative learning and supporting innovative teaching.  Joint Research Centre – Institute for Prospective Technological Studies (IPTS).  Published October 2009.  Accessed October 1, 2012.

3.    Sir Ken Robinson. Bring on the learning revolution! TED: Ideas worth spreading. Published February 2010.  Accessed September 20, 2012.

4.    Salman Khan. Salman Khan: Let’s use video to reinvent education. TED: Ideas worth spreading. Published March 2011.  Accessed September 20, 2012.

5.    CBS News. Khan Academy: School of the future. 60 Minutes. Published September 2, 2012.  Accessed September 20, 2012.

6.  About Khan Academy. Khan Academy. 2012.  Accessed September 22, 2012.

Problem-based Learning …Does It Work?

by Omayma Kishk, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

As the field of pharmacy has shifted towards patient care, re-structuring of pharmacy curricula has occurred.  What once seemed like a foreign concept, problem-based learning (PBL) has become a common theme in not only pharmacy education but in the curricula for many other health professionals.

PBL is a teaching strategy in which the teaching and learning is focused around a specific problem (usually a patient case).  There are six main characteristics of PBL:¹

1.   Learning is student-centered
2.   Learning occurs in small groups
3.   Teachers act as facilitators
4.   The problem (or case) is the base for organized focus and learning
5.   The problem helps to develop and use problem solving skills
6.   New knowledge is gained through self-directed learning.

The beauty of problem-based learning is that it helps portray what a student pharmacist will encounter in the real world.  PBL allows students the luxury to develop and fine-tune their skills; to practice how they would approach these problems without risking patient harm.  Some may argue that students may not be ready for PBL because they will not know where to look or what to focus on.  I personally have a great deal of experience with PBL because my entire pharmacotherapy year as a P3 student at the  University of Mississippi School of Pharmacy used the PBL methodology.  I had a lot of these same concerns and couldn’t understand how I was supposed to teach myself subjects I was not yet familiar.  I was skeptical.  It seemed the student was forced to assume the teacher’s responsibilities.


Student-centered learning is a key characteristic of PBL. PBL is very flexible and can cater to many different learning styles.  Each student can learn in the manner that works best for the individual.  For instance, I enjoyed lectures and liked to hear the teacher talk about things.  I was terrified of PBL because I didn’t think I would get to hear the information.  But, I was mistaken. I soon realized that I could learn about the disease state by listening to my classmates.  I gained so much from our conversations.  I didn’t feel intimidated to ask questions.  Together we shared charts, resources, and ways to better understand the material.

Having a facilitator to help guide the discussions is important to keep the group focused and help direct the students with the case, especially the first part of the case.²  Only when the group is going in a completely wrong direction or developed a significant misunderstanding about the topic or the problem should a facilitator step in. Without this guidance, it would be difficult for students to know where to focus their efforts. In a study examining PBL learning strategies and outcomes among second year medical students at the University of Nebraska, student performance on examinations did not differ when students or faculty members served as facilitators.  However, students said they took more short cuts when a student facilitated the group.³  I recall some of my facilitators that “kept” the group for the entire two hours, forcing us to discuss every detail.  These were some of the group sessions where I learned the most.

PBL can be a daunting experience for students because the student really has to push him/herself to locate the material and study it.  You have to become a more skilled self-directed learner.  Students that have gone through PBL have said it is much harder than conventional didactic instruction.  But it is also more stimulating, engaging, and relevant than those boring, passive conventional lectures.⁴ PBL helps the student, early on, learn interpersonal skills and how to keep the patient’s needs in mind when developing treatment and monitoring plans.

For me, PBL was difficult but now that I have done clinical rotations both as a P4 student and as a PGY1 pharmacy resident, I truly appreciate all of the tools and skills I gained from PBL.  PBL cannot prepare students for every case or problem they will encounter, but it does build the skills needed to help solve problems.

References:

1.   Kilroy DA. Problem based learning. Emerg Med J. 2004; 21:411-3.

2. Ross LA, Crabtree BL, Theilman GD, Ross BS, Cleary JD, Byrd HJ. Implementation and refinement of a problem-based learning model: A ten-year experience. Am J Pharm Educ. 2007;71: Article 17.

3. Steele DJ, Medder JD, Turner P. A comparison of learning outcomes and attitudesin student- versus faculty-led problem-based learning: an experimental study. Med Educ. 2000;34:23-29.

4. Nandi PL, Chan JN, Chan CP, Chan P, Chan LP.  Undergraduate medical education: comparison of problem-based learning and conventional teaching. Hong Kong Med J. 2000; 6:301-6.

Teaching Pharmacy Students to be Excellent Communicators

By Allison Lardieri, PharmD, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

After completing four years of undergraduate education, four years of pharmacy school and now six months of PGY1 pharmacy residency training, I’ve come to the realization that communication skills are perhaps the most important skill I need – and I continue to work on them!  Being a skillful communicator does not require one to know the mechanism of action of a specific drug, disease pathophysiology, or the most recent CHEST guidelines – not that these concepts aren’t extremely important.  But, I have found that the importance of effective, clear, and assertive communication by pharmacists surpasses drug knowledge.

Communication skills are vital to pharmacists every day, regardless of whether they work in a community or hospital setting.  As pharmacists move from a medication-dispensing role to a patient-centered role, they must communicate regularly with other health care practitioners and patients.  In the hospital setting, a clinical pharmacist participating on interdisciplinary rounds needs to feel confident speaking up at the appropriate time and needs to know how to make recommendations in a manner that is well-received by the team.  I believe this is a skill that does not come naturally, but rather can be practiced and refined.  Whether in the hospital setting or community pharmacy, pharmacists have opportunities to counsel patients and need to master the best way to illicit pertinent medical information from patients.  Pharmacists in the community are often pressed for time, and it is important to convey the critical counseling points to patients in a caring and knowledgeable way.  Lastly, communication between pharmacists is another area where being open and assertive allows workflow to go smoothly.  Pharmacists and technicians working together should be constantly communicating about tasks that need to be completed and patient care issues that require resolution.

There are countless times where communication is critical, and as future pharmacy educators we need ensure we train students to become excellent communicator.   In the article, “A Tool to Teach Communication Skills to Pharmacy Students” by Susan Hasan, students developed scripts to illustrate interactions between physicians and pharmacists.¹  Three different scripts were developed based on three communication styles:  assertive, aggressive, and passive.  One of the scripts was turned into a multimedia CD and used for future students.  This activity allowed pharmacy students to explore different communication techniques and improve their communication skills. 

For a majority of pharmacy students, clinical rotations are where they refine their professsional communication skills.  Optimally students should model the behaviors and communication style of their preceptors.  McDonough and Bennett describe several effective strategies for preceptors to improve pharmacy students communication skills.  This includes a thorough orientation to the practice site, establishing pharmacist-patient relationships, and using a counseling model.²  They emphasize that students cannot improve communication skills by just observing, but rather must participate in communication encounters.  The authors point out that feedback immediately after the student-patient encounter is critical as this will help students to improve.  The authors recommend that preceptors think of students as an extension of themselves and train them to be an active participant in the workflow of the practice.

During my advanced practice experiences as a student and now as a resident, I have noticed that medical students are taught about communication skills and case presentations very early in their education.  Beginning in their third year, medical students are required to do a patient presentation daily to the interdisciplinary team and to work throughout the day on patient care issues.  I think pharmacy students would benefit from earlier exposure to inter-professional interactions.  Even as first or second year students, I think activities requiring students to discuss patients with each other and present their pharmaceutical plans to preceptors would help them to improve their communication skills.  This could also be accomplished by having students practice counseling patients in front of other students, where feedback is provided at the end of the session.  By incorporating these informal activities earlier in pharmacy students’ education, it will help students gain confidence. 

One interesting and creative communication activity involves the use of simulated patients and video review.  In a study conducted at the South Dakota State University College of Pharmacy, video review increased first year pharmacy students’ counseling skill achievement scores and helped to develop their self-assessment skills.³  Video review really helps when giving feedback to students.  I think it is important to have informal opportunities for students to learn from video review prior to using video recording for assessment purposes. 

Communication skills must be taught and students can only improve their communication skills through practice.  I recommend a mix of formal assessment activities and informal opportunities to practice communication beginning early in pharmacy students’ education.  Informal activities can include having students present a patient to a faculty member or counseling a simulated patient as part of a group activity.  The formal and informal use of video review is also helpful.  Feedback by the faculty member and peers can be provided to each student following the activity. I think we teach pharmacy student to be excellent communicators, but only if we start early!

References

1. Hasan S. A tool toteach communication skills to pharmacy students. Am J Pharm Educ. 2008;72(3): Article 67.

2. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effectiveprecepting. Am J Pharm Educ. 2006;70(3): Article 58.

3. Mort JR, Hansen DJ. First year pharmacy students’ self-assessment of communication skills and theimpact of video review. Am J Pharm Educ. 2010;74(5): Article 78.