Improving the Feedback Conversation: Role of Mentor and Mentee

We're gonna go ahead and get started thank you all so much for coming joining us afternoon I think it's important to know if you all I loved seeing so many people here that last people online also it's important to note this is similar attention to what we had before when I say similar I mean the title does name sorry feedbacks about feedback one of the reasons we tend to have a feedback session almost every year is a every year it shows up on our need assessment every time we do an evaluation you know at the end the suggestions we need more seconds on Pisa so we this is not the exact same session that we've had before this is what we're trying we try to do is offer a little bit different but complementary perspectives and the topic lots of folks have done in the past that release tickets on it I've done it Tommy have done it and today we are very fortunate to have dr. Rebecca Polly leaving our session in time feedback and this is a this is a part one of two sessions so stay tuned for the second as soon as you come and dr. paul ii also has that burger lean the hall who will help her with some role-playing and we may have some other dreamers that rope fling testing out their evidence feels please join me welcoming definitely better quality thank you and is is this the microphone you don't don't have to use it i was it great all right well good afternoon thank you for joining us so today we're going to talk about some skills that I want you to walk away with that you're going to be able to add to your toolbox that hopefully you'll find very useful in the feedback conversation so our learning objectives are to recognize the importance of active participation on both the provider and the receiver of feedback and to realize it's dynamic and data-driven the conversation and as I said we're gonna pick up some tools and understand that both the mentor and mentee or the person providing an odorous eveing the feedback has the ability to practice and develop these skills so what are some examples of places where feedback can play a role what you typically think about the learner and the teacher the intern and the resident may be other places where we see this student in the resident the mentee and mentor an employee and supervisor peer and peer sometimes we don't think about that and the faculty member and the chair or she is another exam feedback is described early on in the 1980s by Indiana's famous article in medical education as an informed non-evaluative and objective appraisal performance intended to improve clinical skills this information that a system uses to make adjustments in reaching a goal I think frequently we think about the endocrine system as the loop back so that takes information and then we look back and we see a change in output of hormones to improve the situation its formative is adaptable we're evaluation it is summative it comes at the end is final it's definite it's not changeable its judgmental it's an action which highlights the difference between what's intended and what's the actual result and it allows for growth it should include preparation from growth the receiver and the giver of information and I was having a conversation earlier today with both my kids who are their twenties and they were saying you know what's on your schedule for today and I said I talked about feedback and they both went oh we get so much feedback and I thought you know that's interesting because I also hear from learners that we don't get enough feedback so it made me think a little bit about the Goldilocks phenomenon that there must be this whether it's too little or it's too much but there must be this perfect somewhere there's this perfect amount of feedback so I started quizzing with them a little bit more about why do you think there's too much feedback and what they were really describing I think was more evaluation than feedback it was a comparison with their peers rather than information about their own performance so as we're thinking about feedback we're gonna talk a little bit more about how feedback should follow learning objectives and it should be really directed at that individual and it also it appears it depends on the climate and the culture of the organization so it's a process that involves a two-way non-judgmental communication and as I said it should follow clear expectations that are laid out in the beginning so in the beginning of a rotation in the beginning of a course it needs to incorporate what the learner wants to gain from that rotation so it should be a dialogue it shouldn't just be the teacher saying this is what I'm going to instruct you on it should be a conversation of what would you like to get out of our encounter what would you like to get out of your time with us in clinic and then you create the learning expectations and then at the end of your time together you look back and that's what you provide the feedback feedback is used to appreciate the good things the right things with a logical explanation of why are these goods what did you do well it has to identify the bad and wrong things and provide logical explanations and options to change it should allow for follow-up and to assess implementation of the suggestions and look for improvement so there are generational influences although these are widely applicable so you want to create teaching moments and feedback moments and again stress the learning objectives state clear expectations what is required of learners and you want to name it as feedback a lot of times even when we give our best efforts of providing feedback and then you've asked learners did you get feedback and they'll they'll frequently say no I didn't get the feedback and we feel like we have you know given an abundance of feedback so if you say do you have a few minutes I'd like to give you some feedback now then I hear that is feedback and then as I said provide next steps to improvement and be specific so works are important and there are phrases that we frequently use thinking we're providing adequate feedback but they're really not effective phrases for feedback good job you are a real pleasure to work with you're such a great team player we showed improvement you're you're nice and friendly you're a hard worker your hearts in the right place or as we say in the South bless your heart so these kinds of things you know really they're they're not helpful they don't give you any information that you can anchor on and know what the person did or for the person to know where they go next right it's sort of like if you're at a restaurant and the chef drops by your table and you say oh yeah the meal is great so that person doesn't know where it were to bill what to do we in contrast if you say we know that the ginger sauce with that special lime and the seared scallops really cleared nicely with the song Mian Blanc well you know chances are they're gonna probably keep that on the menu because they know exactly what you appreciate about the meal so in contrast to these if you were to say to the resident when you were willing to see two additional patients in pre-op clinic and allow your fellow resident to leave early to prepare for the student lecture I felt you showed significant maturity and concern for the efficiency of our clinic chances are the resident will do again the residents going to realize that you noticed and if this mattered I noticed you checked on one of the students who seemed swamped and then taught how to organize admission orders great skill at being observant and teaching something useful and what it been a stressful situation so you're encouraging behavior to be repeated and you're identifying a behavior that the person did you're providing feedback that's going to encourage this to be repeated we can also do this with our peers and this is an example of that would you be a bangle or to share your technique and teaching to the moment and providing immediate feedback with our faculty in our section I was so impressed last week in watching your teaching these kinds of focused teaching moments in a busy clinical situation or just what we want to incorporate into our teaching environment and make a name for our section as excellent teachers we could all benefit from your skill and expertise peer mentoring and helping our faculty provide feedback to learners in the moment will help us all maybe we can even convert this into scholarship so you're identifying exactly what your colleague did and providing feedback to that person likely it's going to encourage him or her to continue that type of teaching and then you're also going to reap the benefit for others so now I'm going to launch into a few role-playing examples and what we're going to show in the beginning is how not to provide feedback so those are the down arrows the sort of bad examples they may be a bit over emphasized and then we're going to show better examples and we're going to have a check-in moment with both Guerlain who is some situations will be a medical student in other situations she is going to be a resident and then also we're going to stop and get your input as well what you thought about the particular situations and then we're going to have some opportunities for you also to roleplay up front but then we're going to pair up in the audience and then we'll get back into some more content as well so our first one internally if you'll come on down is feedback should be solicited rather than imposed so Darlene is a third-year medical student she is on the inpatient ward service for internal medicine and she's been with us for two weeks and it's time now for her valuation so it should be solicited rather than impose so the not-so-great way to do this sterling so you can look at us a couple of weeks now and you know the medical school requires evaluations I really don't understand fully while I at this midpoint but regardless of that so you know but I've got a lot of time but it's time for that my getting these emails so just a couple of minutes we can fill out this form sure with this work now sure okay so my office is always in the minute building too far it's just over here okay short average snow fell to sehorne's a couple of boxes right here so I think everything's going okay if you say so you know work well with the team I'm gonna check that why did we meet your objectives it says I can work well with others and I tried to put a piece of things oh yeah color-coordinated good job alright look anything I can write your letter okay all right so not not so good right alright so it should be solicited so at the beginning of the rotation darling we're really happy that your honor of rotation I've heard through the grapevine you might be interested in come with us I'm very interested yes okay so at the beginning I'd like to talk the students and see what you want to gain from Intel medicine have you thought about some of the learning objectives said that you might have to me I do have objectives that I need to learn who provides but I think just letting all the team works and what you know our roles would be as a future in turn one day and just learn new dynamics I think would be okay so the dynamics of the rounding team okay and then as far as what kinds of patients have missed your first inpatient retention team is my first okay - okay he has some responsibilities sometimes that you know where you've been on the team and can be a little bit intimidating I will say that patients are best teachers okay so when you get a patient read about that purchase those problems that he or she has and those things will stick with you forever so just take that as a learning opportunity and as a student you can be the best advocate for the patient because they get to see you more than anybody else on the team and so take that as an opportunity I agree thank you and you've had a lot of practice ride with the district assault staff so I think the history of present illness is really the most critical piece so I wanted to be a lot of practice getting the history and then presenting on rounds and then we'll spend a lot of time working on your history of present illness and your write-up exactly so when it comes time to give you feedback that's where I'm going to spend a lot of time giving them feedback I really appreciate that thank you okay so now fast forward to our midpoint time so throwing we talked about your learning objectives that we're going to spend a lot of time on your history of present illness and your presentation as well as the write-up so I've reflected back over on you've probably made about probably 10 to 15 presentations over the archon weeks together and I want to first get your thoughts why don't you think about how over the course of time which that went so I think in the beginning I was a little bit more shy and not as confident that I think with the residents helping me and you helping me I think I got better to go the rotation okay and I agree with you and I would say by better I felt that much more detailed and more efficient and I thought that along the way from we asked you to add certain aspects to the presentation you just don't find on that so you really balanced detail without the too extreme so you really honed in right on the what we really needed to hear and I'm particularly like how you were able to to build and create your own generation document so how that was a huge road just work on that especially for you know to stay in your first rotation so particularly impressed with how you go both potential finances thank you so I look forward to working with you again maybe as you're acting internship rotation that would be wonderful good so it's we built together us based on learning objectives specific to her and gave the specific visa so that's that piece thoughts questions how did you how did you feel with being able to give your input around the I think giving input always teachers are a team player as far as evaluation and feedback goes just because it's not you know just hearing information you're able to speak up and sort of share your thoughts as well first one obviously wasn't that abrupt uh-huh but I've seen that happen to and or detailed but more appreciated Sharon I love Linda knocks when you're doing that facilitating a feedback session and you ask them first you know how do you feel in Flint and without immediately jumping that is you're putting it back Rhonda oh really what do you think well economic insight that part was bad right and they they were not playing the Union because you also made for example offense nested we've done well for so many wasn't just community about my book beat back more than just one thing but I will learn while this person you knew aloud Rebekah's do you have a pack of trying to remember some of the specific things about each of the trainees on the team because I struggle with with the specificity part sometimes you know when you got an upper level resident here resident medical students it's time for that you know to week or indentation evaluation you want to try to avoid those try generalities that sometimes I struggle to remember some of this at six and one sometimes I'll jot down you know at the end of rounds if something really stood out or a particular patient encounter if there were a patient who was particularly challenging and a learner had you know was a real advocate for that patient who everyone else maybe had given up on then I'll make a note of it that they went you know the extra mile and then you know and I'll make a note of it so that I don't forget about that also I think if catching it in the moment helps because otherwise I might miss it you know so don't hold it for that two-week so just pull them aside after and say you know I thought your interaction today you know with Miss X was very remarkable I saw that you know so that you name it right at that point be helpful if you have if you have a particular burning feedback like that move you tend to like to pull them aside or is that an opportunity to maybe say that in a small group just so that you can give feedback to the individual and you can also help you find the private that you kind of want and expect everyone else to write at I think that's a good point too and also I think you can you know bounce it back to well how did you feel about that you know and I as you're talking about that it makes me realize well what do you do if is something that's negative and do you only can you use a negative to teach others in a group you know and that gets a little stickier right I mean we're we're more willing to say with learners great job let's showcase you in front of everyone else right but do we take that opportunity and I don't I don't have the perfect answer for that you know but do you let that go right when everyone else around realizes that probably wasn't the best way to handle that but I think you can debrief as a group and say how did we feel about that and make it a wee potentially actually wrongness of what they've done the encroachments of what they've if you ride a whole group right so it all depends on and one of the slides later on it talks about if we don't identify or if we don't provide feedback then we let it go and it you know is assumed that it was you know done correctly which it described earlier in terms of the interaction you asked for a healthy man another way to get that because sometimes people get stuck with just thinking so the big question is what what went well you know what didn't go as well as you would like what would you do here Nelson fits in with just it's a teachable moment you don't have to pound them best thing you just say that's what I had to do it over again I felt stuck here I want to try chamber that it allows right to it name it as I wish it had gone a different way great okay so I like this discussion and I think some of it's definitely better than some of the these more contrived examples but we'll go through some of these and see if we can get a good discussion around them but the point here is focus feedback on behavior focus on behavior rather than personality so the example I do that we pick here is shyness so curling you know on rounds I've noticed that you're you're not speaking up so I think that's because you're shy so my suggestion is the power stance so just spread spread your feet apart stand from the mirror and practice okay it's time not to be shy okay I can be strong now HR medicine is not you know the on the spectrum I think surgery's maybe a little more power or you know I'm just saying so I want to get you ready okay okay we're working on power stance practice I don't really know how okay okay so we're making the assumption she's not speaking around she's shot so that's the personality we're not you know making the assumption we're probably not gonna change that so early on Browns you know I noticed after rounds you're we talked through all these answers on rounds the dynamics you're not speaking as much tell me what's up with that and I just get tongue-tied and I don't feel comfortable as a lot of people okay is it I mean I know we have a lot of personalities on rounds and some folks is it is it the hierarchy that maybe the residents some of them are jumping in with answers sooner are you trying to find your way in with that I guess I just don't want to be wrong what I do say any answer so I just I don't see anything okay well I've been trying to think about ways we end up with that so when did help do you think if we took turns and went around for the circle it rounds I think that would help okay because you know sometimes folks who like to talk jump in above maybe the spider people and in part or folks who actually know that answer get stepped on by these other pros what do you think that would help if I just said but why don't we to give everybody a chance and I'll just call up but with that I think so okay yeah because I feel like if I'm almost ready to say an answer and then somebody else jumps in and then I don't say anything at all okay because what I'm worried about is that it might just be assumed that that you don't know the answer right where that's not really the case because when we're one-on-one you know you're you're giving me the notes or so so rather than assume it's a personality issue try to figure out the mechanics and work with that so comments thoughts have you seen that on rounds for the dynamics of rounds for certain folks are much more likely to to be the talkers and you you know a lot of times you kind of let that go because so much giving you an answer and it's it's kind of easy and just move on and you know those people talking it you know gives activity and Slive Lemus and you kind of forget about those folks who are quiet and anybody hasn't thought about that at all or okay so you know what we're not going to at this point in time be changing people's personalities but okay comment whatever whatever everyone grabs I ask specific people questions and I delivering that go right down the team and get everybody you know just so that somebody can't get lost in the shuffle mm-hmm if they don't know it's fine drop one okay that's an abundance you have to make a point of engaging each person on the team because if you don't yeah some people just keep their mouths shut and hope they could fly on delivery mm-hmm and I think people do that for different reasons right I mean yeah okay limit feedback to the information the recipient can use rather than the amount we might want to shoot okay so early you know your write-up that I got so I decided to limit it to the top 15 things that I want to do it away because it might be a little red but just seeking work on this account sure all right so probably over one lane not going to happen she's just gonna you know take it go home and put it aside so have you thought about on the write-up what was the area that you want to focus on I think the discussion portion of it I wanted to get your input on a little bit more okay so that's great because that's what I decided to work on and what I wanted to do a little bit is if you can tell me not just why you included certain of the differential but tell me why not okay okay so what things did you rule out and why did you rule them so if you would include that mm-hmm as well that helps me so then if you have to look back around to include your next level and the inferential will be able to see which ones we can pull back now that's a good point okay okay okay comments thoughts yeah one way to avoid the bolas effect is to get a multiple feedings of this feedback because if you if you're working with the residents for a week and then you give them the feedback to the week that formative evaluation becomes summative evaluation and so it's much better giving them every few days when you have then note the good things and these can be improved on and then if small pieces can get have time to get better so that we should evaluate those the value you're signing is helpful and you can also pick up from them along the way too right so maybe they'll change and say okay I got that part now I'd like to work on this part other thoughts get feedback only on something that can be changed so I think sometimes we let off steam and the resident or student is the bystander and it's not really anything that they can work with or change so early you know our our clinic is not as efficient as I would hope so what I've been thinking about and now she's the residents so we're in Resident clinic I'm finding that there's a long line patients when they're trying to check in so what I wanted you to do was get an iPad and go out front and if you could check people in oh okay so I don't know why it can't be faster so I know there are like three people out there but surely you can go through some of insurance things right and get that interview probably not but I'll try yeah try is our mother okay okay so I want you to go out and see if you can't get that done so they don't have an iPad that's very good we just want to be more efficient if you don't think that works then maybe our steps should be in parking so as they're coming in the park boundary I get sign Riverside three internal medicine and they help people come on up okay do we take turns doing that so this you know it's a fixed problem probably not the one to solve that okay so efficiency in the clinic have you given any thought to our no-show rate and maybe how we can make that better life after visit phone call see if the patient has any questions about medications or follow-up or pharmacy and then what if you guys brainstorm about that so I think we were just talking about it the other day maybe sending a personalized letter few weeks in his fans kind of letting them introduce ourselves to the patient that were left in clinic and that they can come in and bring their medicines and I think you've seen a good response to that people are ok showing up more so you're doing it ahead of time ok and you're finding that's been helpful I think so we haven't you know you just looked at it for a few months now but I think that would be a good point or I think you know the no-show rate if there's time you can always of course do the post visit something ever call them and see why they didn't show up I'm tired of various things we can do so that's something that's proactive is something they're involved in you know potentially is their patient so there's more engagement right so ok so something that could be changed comments thoughts I think this would be kind of hard like procedural you want to get feedback but I think sometimes it is hard because your carrying one person to another person kind of start you said commander is fast not saying it can't mm-hmm but that also make the entire county student receivable yes that's a tough conversation lieutenant I struggle other people tended to be changed for Kansas we change yeah mhm his partner every bride it's hard for me sometimes to figure out what really heavy well I guess you know you've been thinking about that if you report metrics to them or this you know if you're thinking of timing or efficiency and maybe they don't know what is sort of the you know the the bell-shaped curve or where they lie on that or how do they get to be more efficient at a certain procedure you know so they don't really know what what is the gold standard or how far are they from that they only know themselves or they only know as a student themselves compared to seeing the chief resident do it so they may not know how far they are off I think it's important that you submit ivory yeah this is an example well you told to be records probably you know you're not able to you know really relate to each other and then another faculty member of leadership if you're attractive down like on leaves and interaction with the children on their level you know there are things about this but you know these things that you think and if they can't make that they can't cut them up you're like if they're still saying without power lady they're not thinking and then there's something else but just trying to make it okay Thank You Berlin and then this one is just meant for faculty preparation with the concept of thinking about as we go in to our annual or semiannual review with our chair or section chief that if we're not prepared then we can be blindsided so the down arrow would be you know I'm just I'm just gonna walk in blindly not really knowing my rvu production or my scholarship effort for this year versus I'm going to get all my ducks in a row and I'm going to think about my own goals for next year and I'm going to be more prepared so that's the concept of the up and down arrow there so what determines whether we we respond to feedback or not well respect and Trust on behalf of both participants emotions knowledge and belief in the data the stakes so the stakes can can be low medium or high and it's been shown that in a feedback situation if the stakes are too low then the person is not going to respond to feedback so if an example of this might be for internal medicine if it's a third-year resident and they're in your outpatient clinic and they're in the last week of the rotation and they're about to walk out and don't enter their practice and you say oh I wanted to give you a little feedback on how you've been doing the stakes are pretty low at that point for them listening to you if the stakes are too high they're about to walk into a board exam and you're like you know I really wanted to talk to you about your rotation well their stakes are too high for that exam for them to pay attention to you so you want it to be kind of right at that sweet spot to pay attention they do want to have some sort of ability to control what they hear from the feedback to respond and then it needs to be in a supportive environment so how do you establish that supportive environment what it needs to be the mutual respect and Trust needs to be a belief in the data using an appropriate location going back to those mutually agreed upon goals and setting the learning expectations get their thoughts and feelings and inside is this something that's doable and you know we create agendas all the time with patients so we need to create an agenda with our learner our peer and then arrange follow-up so I just want you to reflect on the this question how often when you get feedback have you asked your learner or mentee what they want to get about out of the interaction and then think about that and then how often have you changed a feedback session based on what the learner said he or she wanted to get out of the session so I've thought about in reading over this question again I was thinking well you know that would be kind of a neat way to start the feedback session so what do you really want to get out of this feedback session what is it that you want feedback about right I mean we're like programmed to give the feedback on this whole big in you know interaction for two weeks that we've had but maybe they only want to hear about this one specific area that they feel like is the area that they're most efficient in so you know that Pete that part combined with what were your learning objectives for this rotation and that really gets a conversation that will be geared on where they want to have their growth okay so what happens that we don't get feedback well the performance is not reinforced in poor performance remains I'm corrected so we may have sumo as well we may rely on hearsay we have to guess level of competence you may have to learn by trial and error and then that could become a patient safety issue base just going with what we think is right so you've probably heard about the feedback sandwich which was the old breads on top that's where you begin with something that is positive then you go to the meat of the sandwich or the portobello mushroom of the sandwich and that's where you say what you really want to say and then you end with the bread which is now a positive well that's been shown not to be so effective and most of my students in the past would be like okay just tell us what's in the middle they hadn't enough that they knew what was coming but what has been found to be more effective is what's the Pendleton model which is a modification of that where you ask the student this is a four layer sandwich you ask them well what do you think you did well and then you comment on that and then you ask the student well where do you think you could improve and then you comment on that so this has been shown to be more of a dialogue and then therefore to be more effective so this I'm just going to show this form because I think it allows it just reflects on how to be specific so again going back whether you use a weekly form a daily form a monthly form think about it that it should relate to the learning objectives this particular one was from an anesthesiologist what did the student do a resident do well what what could they do better what would would you like to see them do tomorrow and then add additional comments so we're going to work on a couple we have about 15 more minutes and this we're going to practice because as Benjamin Franklin said by failing to prepare your prepared preparing to fail so it's going to ask dr. Weiss if she might help us out a little bit because she know I've had some conversations related to feedback you know this is a passion of hers so she was going to come up and help us coach one of our faculty who's gonna volunteer gharlane's coming back up now she's changed her residency tuned OBGYN and she wanted to apply to urogynecology so I was gonna see if do you still have time or do you have to scoot away okay yeah so dr. Carr is our faculty person wonderful darling it's not doing quite as well OBGYN as she did in intro medicine but she was interested in applying for fellowship and asking dr. Carter for recommendation and I'm gonna move it down here right just put this up to sort of help out so she thinks she's done really well but apparently her clinical confidence is not quite as strong as as she has thought so she's seeking advice and wanting to get a letter for fellowship I mean all right so tell me what brings you in to meet me today so I'm really interested in assumption popular disease done and I'm just wondering if I could have some advice and perhaps maybe a letter recommendation okay um can you tell me a little bit about why you're you know what you're looking for in priority Christian Fellowship and tell me a little bit about how you think the past will say two years two years of residency events of so I mean the costume is about Medina don't buy okay search everything around let its activities and I was a little shocked but I think they've been it's okay okay but I think with the fellowship I think if you should have expand on my love for what what do you think have been I guess your greatest strength so far clinically as a resident - I think I do well with teamwork I'm going to think with recognizing certainty emergencies that happen in OB during like my night shift or finding no by myself that my train that somewhere else or taking care can work for I think I do well with working okay what sort of challenges have you faced and what do you think ill want to work on over the next year or so as you apply the fellowship yes I mean I think it's working more on getting comfortably more comfortable with being a solo practicing well I guess what I would say is or you know first always really excited to have someone interested their specialty I think that we should meet and talk a little bit more about you know what's brought you to Yerevan specifically what you're really looking for for your career your career goals and and how we can meet those and I think that in terms of your residency training you're absolutely right it can be really challenging just switch fields so that's definitely a little bit of a culture shock so one of the things that maybe we can do is look over some of your evaluations I think there there have been some challenges that have been identified that maybe we can work on to strengthen your application for fellowship and and probably try to list those but I wanna take up some time okay so me - senator yeah senator pub so I think you both did a good its first of all it's really hard to do this in front of other people right differing you know people I think you know you both did a good job I think not only with you opening it up and asking her what brings you in today it really you know rather than saying so I I understand you know my admin told me you're here to get a letter of recommendation right let's just narrows you right now right because then you're you're kind of play between a yes and a no or a good or a bad or a locked in to either a really good job team just sort of like we get patients what right what brings you in today and see what page they really say you know you did it's heart rate we don't know a ton about urogynecology information so I think you got her to talk a lot and if you get if you needed that was really good is you did find a way to leave in there well let's talk about what some of the challenges might be able to review your evaluation so you're giving some objective things C tied in evaluations and to feed that right without saying oh that's really great I love that people are going to yoga and I'll do whatever I can to get you in that's kind of a false promise and then but also saying you know wow you really have a lot of things on your evaluations and their last two years that you really need to work and I just don't see this happening so you did overly encouraged and you didn't overly discourage and I think sometimes that's hard for us but it also then people really take you for being truthful in you set the right stage so your feedback in the future means so much more when you can say the tough thing that you can also say you know they're really the good things good things too great thank you other comments about that interaction that we've kind of all been there that was a great illustration in the question yes I think one of the things that I find really challenging is giving professionalism take feedback and that's you know something that can happen but not really any level this I should students or residents and so especially when you're ignorant companies and then about applying to fellowship or applying or they say you know they want to find their special team and also because sometimes they can overlap with the personality so you're trying to extract the you know either punctuality issues or you know from maybe maybe it's a personality clash that's not necessarily the change and trying to adapt that to give these suggestions for that on this sort of professionalism concerns especially well I think I don't gets too insight yeah makes it great so you know whether the person can identify does the person have any insight into that behavior and if they don't I think the most Ryan Jahnke Nvidia and you know you said you've got like you you know your teams are commenting that you're never on time around they're like what uh you know so that well so can I can I move to our next role play which Anoush around that because if we're I was going to actually have us pair up doing something around that and I'm so I'm kind of putting a little bit just to see what we get with this yeah and so I'll come back just because I have I'm gonna get one more questions surround the one thing is struck me about this conversation right off the bat was it was way too late somebody is coming to you I want to do this can I get a letter right and there's a problem section has been identified two years ago that's true and it may have dropped because she changed right and it may have dropped because thoughts expectations and it may be in a head there have been other conversations right that others have told things but but you're right so I'm gonna move now with this side of the room being the residents and this side of the room being faculty and if you can just turn to your neighbor and what we're going to do is this is around professionalism it's also a component of feedback and you could call it difficult conversations but so if you'll just pair up with the person next to you and for the residents it relates to sign outs so resident number one who doesn't provide the best sign outs most of them you just give the name medical record number in diagnosis and resident number two is the person who is receiving these not-so-great sign outs and you've had enough of this so you're now you're gonna give feedback to that other resident about wanting to see first of all there's any insight on the part of that person and then how you might work together to change that okay if there are three of you maybe you can turn around to the table behind you and make it in pairs and then the other side is the faculty and this relates to coverage so faculty number one is always the last to get to clinic always has conflicts is always leaving early if faculty number two is kind of had enough of that and so we want to check in again about inside and see if you can give any feedback around that so I'm gonna go back to right so let's just see how far we get a man know this is tough but I think if we just get through the inside piece that'll be okay to determine because it'll be something you can carry with you I'm not saying we're gonna solve this problem in four minutes but just see how that plays with the number one person is the problem person who's not doing much on sign out and number one faculty is one who's always late always leaving early their world problems are more important than anybody else's and you know determine if they have any insight maybe they didn't realize they were doing this maybe they didn't realize that everybody else's sign out was much more extensive or that it could have any impact on clinical care so let's six four where this plays out that's a little bit of how you're gonna get feedback to that person so in closing I just wanted to say that constructive feedback is one of the four pillars of mentoring and others are generosity listening and the objectivity just to remind you how important constructive feedback is and hopefully well I just also want to give a [ __ ] for peer feedback which the teach program offers which is very helpful and it's truly formative and then this can be used in your promotion portfolios and hopefully today we have learned that effective feedback is something that should follow learning expectations that is designed with the learner and the teacher is dynamic and data-driven it's a skill that we can practice and it forms one of the pillars of mentoring so thank you for your time any questions in the last minute or two and comments thank you.