A Soundboard Approach to Facilitate Effective Feedback to Health Professions Trainees

Abstract

It is well known that health professions trainees benefit from feedback that is timely, constructive, and focused on observable behaviors.  However, providing such feedback becomes increasingly more difficult in situations where either the stakes (possible negative outcomes) or the trainees’ resistance to the feedback increases, or both.  In this short communication, we use the metaphor of the sound engineer’s soundboard to highlight the benefits of being adaptive to the interplay of these two factors when giving feedback to trainees in these difficult situations. We describe and illustrate the metaphor and then share educators’ responses to it.

Background

Health professions trainees require feedback from science educators that is effective: timely, constructive, and focused on observable actions and behaviors.1  We define “trainee” broadly to include both pre-professional and post-graduate students and “science educator” broadly to include teachers, mentors and preceptors.  Best practices in providing feedback exist2,3 and often work well in routine situations. Nevertheless, we have observed that these practices generally do not explicitly consider: (1) the stakes (high or low) or possible consequences of the situation necessitating the feedback to be offered; and (2) the extent to which the trainee is resistant to feedback.  We have observed from personal experience that the quality of the feedback can be impaired if the approach to giving feedback is not adequately adjusted to account for these two factors. This dynamic between quality of outcomes and the attention given to underlying conditions reminded us of the challenges a sound engineer faces when using a soundboard to modulate the interplay of multiple inputs to produce an harmonious output.  A soundboard is the electronic console used in live and recorded performances on which there are input channels with sliders that are adjusted to obtain the right sound mix.

Figure 1: SRM Soundboard Axes
Figure 1: SRM Soundboard Axes: The X axis of the SRM Soundboard indicates the stakes associated with the situation for which the feedback is being given. Low stakes are at the far left and high stakes are at the far right. The Y axis indicates the trainee’s resistance to feedback (positioned as the reverse of receptivity in order to align the axes), with low resistance (high receptivity) at the bottom left and high resistance (low receptivity) at the upper left. The placement of the gray bubble indicates the perception of the person completing the SRM Soundboard of the stakes (low or high) of the situation and the degree of mentee resistance. The diameter of the bubble indicates the difficulty of the feedback to be provided, which determines the level of mentor skill required for the feedback encounter.

By building on this conceptual association, we developed the SR (Stakes/Trainee Receptivity) Soundboard, a metaphor to illustrate (see Figure 1) the educators’ task of adjusting their approach to giving feedback to accommodate the stakes of the feedback situation and the trainee receptivity to feedback.  In our model, the educator is envisioned as adjusting these sliders, as if on a soundboard, to obtain the right mix for a good outcome in giving feedback.  Just as with a soundboard operator, the more highly skilled the educator, the more adept they will be at recognizing which channels need attention.  For example, if the educator applies advanced skills, they may be able to reduce the stakes of the problem.  If the trainee is resistant to feedback, the stakes of the problem may increase and the situation may require greater skill on the part of the educator.  A sound engineer knows that all sliders can move independently – none are stuck in place – so there are a large number of possible variations for the mix to create a harmonious outcome.  In the same way, all of the variables influencing the ultimate success of feedback given can be seen as modifiable in a particular situation.  Such insights might lead the educator to consider how, given their skill level or the trainee’s receptivity, they might break down the issue into its constituent parts, each of which is perceived as being lower stakes than the issue in its entirety.  Or perhaps the educator will seek out a more experienced educator to improve their skill in providing complex feedback to an unreceptive trainee, or to assist in providing the feedback.  Application of this conceptual model also allows one to envision the educator-trainee relationship as a melody playing out over time, with the sliders moving as needed and taking into account feedback discussions that have come before.

Activity

Our use of the soundboard metaphor involves tuning the axes on Figure 1 to provide the best “mix” of the two components to realize the ideal “sound” or outcome of the feedback.  Mix 1 (low stakes and low resistance) represents a best-case scenario in which well-established feedback models should be successful and in which educator skill in providing feedback may be relatively less important.  Mix 2 (high stakes and low resistance) represents a more challenging feedback scenario, such as delivering difficult news to a highly engaged trainee, which will require more skill on the part of the educator to provide effective individualized academic support or resources for the trainee.  Mix 3 (low stakes and high resistance) may require more skill on the part of the educator to discern the basis for and to address the potential negative impact of low receptivity on the part of the trainee.  The educator’s ability to address the receptivity of the trainee will impact the effectiveness of the feedback given.  Finally, Mix 4 (high stakes and high resistance) represents the most difficult scenario for educators to provide feedback to trainees and may involve lack of resolution or escalation of a previously addressed issue or a new, difficult issue with a trainee who is unreceptive to feedback.  Mix 4 scenarios will likely demand the greatest skill on the part of the educator to provide effective feedback to ensure resolution of the issue and maximal trainee professional development.

Importantly, the SR Soundboard metaphor highlights that the conditions in which feedback is offered can vary as an individual feedback encounter unfolds over time.  Low receptivity/high resistance is a trainee-dependent factor.  For example, among medical students, less experienced trainees tend to value positive feedback more highly than constructive feedback, while more experienced trainees tend to value constructive feedback more highly than positive feedback.6  The extent of resistance may also vary as a consequence of context, even if the actual feedback being provided is similar across two contexts.  Likewise, the overall complexity and, ultimately, the success of the feedback situation can vary independent of the level of trainee receptivity, due to differences in the level of skill the educator brings to the situation.  We believe this model will allow educators to identify these conditions more precisely, especially as they unfold during the feedback session and, therefore, increase the likelihood that the feedback encounter will be successful, particularly when interacting with highly resistant trainees or for high-stakes issues.  

Figure 2: Using the SRM Soundboard to Track the Progress of Feedback
Figure 2: Using the SRM Soundboard to Track the Progress of Feedback: This figure presents hypothetical feedback scenarios illustrating the influence of differing degrees of mentee resistance and mentor skill on the evolution of the feedback scenario and its complexity. In both scenarios, the mentor’s perception of both the stakes and the mentee’s resistance are initially the same; however, as the feedback session evolves, it is apparent that the resistance of the mentee in Scenario 1b is higher, as reflected by the mentee’s response (text box 2) to the initial statement from the mentor (text box 1). Consequently, bubble 2 in scenario 1b is higher than bubble 2 in scenario 1a and its diameter is larger, as the complexity of the feedback to be provided is increased. As the feedback session evolves, the influence of mentor skill is evident in the movement and diameter of the bubbles to different locations for 3a (high degree of mentor skill applied) vs. 3b (low degree of mentor skill applied).

We introduced the SR Soundboard to educators from across the health professions, in three different sessions using professional actors to portray trainees in a simulated feedback scenario in which the feedback complexity varied as a function of trainee receptivity (see Figure 2).  After each simulated conversation, we debriefed by reviewing the maps to identify places where the conversation might have gone differently, and where it went particularly well.

The simulated scenario involved a scholarly writing project (e.g., class assignment or clinical note) that was not well written and bordered on plagiarism (e.g., cutting and pasting); however, the situation is “low stakes,” because it is occurring early in the course/semester/rotation.  A “low resistance” student (Scenario 1a) may be one who is very receptive to receiving feedback and wants to be a better writer, but doesn’t know where to start or how to improve.  This student is open to resources the mentor can provide. This is an ideal combination of a low stakes’ situation, low trainee resistance, and high mentor skill; thus, a successful feedback encounter is likely.  Conversely, if the mentor skill is low, the mentor may be frustrated that this trainee lacks basic writing skills or ethics and may feel that it will not be possible or is not their role to mentor this trainee on basic skills that should have be acquired by this point in the program.  In this case, although the stakes of the feedback situation and the trainee receptivity have not changed, a successful outcome may be less likely. Similarly, one can envision this same scenario of the “low stakes” writing project, yet the trainee resistance to feedback is high (Scenario 1b); the trainee thinks they are a great writer, has always received excellent grades/remarks on their writing, and feels as though their writing is acceptable and not plagiarism.  In this case, the mentor may be concerned about the seriousness of the problem, but realizes that the feedback situation is more complex, as they must first must direct the feedback to increasing the trainee’s self-assessment capabilities and understanding of the problem from the standpoint of ethics and writing skills.  Only after the trainee has a more realistic assessment regarding their writing skills and an appreciation of the ethical aspects of their actions, can the feedback turn to improving writing skills. Alternatively, if the mentor brings a low level of skill to the scenario, they may be frustrated with the trainee’s lack of self-awareness and inability to take responsibility for unacceptable work.  In this case of high trainee resistance and low mentor skill, a successful feedback encounter may be less likely. 

Results and Discussion

We piloted the SRM Soundboard in three workshops with faculty from across the health professions, using professional actors to portray trainees in the scenarios described above, but with no scripted dialogue or determined outcome (see Figure 3).  After two of the three sessions, we obtained written feedback from participants in a post-session evaluation that indicated that the visualization of the encounter provided by this SR Soundboard is highly useful in understanding the progression and transition points in a feedback encounter. Based on this feedback, we conclude that the SR Soundboard is a useful metaphor to objectively capture the major factors that contribute to the mix of a educator-trainee feedback encounter.   

Figure 3: Actual feedback scenarios with different levels of resistance to feedback tracked in real time using the SRM Soundboard
Figure 3: Actual feedback scenarios with different levels of resistance to feedback tracked in real time using the SRM Soundboard: Actual feedback sessions tracked in real-time by an observer in which a single mentor provided feedback regarding the same scenario (i.e., equal stakes) to two different “trainees” portrayed by trained actors. As the feedback session evolves in Scenario 2a, it becomes clear that the mixing of the mentee’s receptivity and the mentor’s skill leads to a decrease in the stakes and in the complexity of the situation, as reflected in the movement of the bubbles to the lower left corner and the progressive decrease in their diameter. Conversely, in Scenario 2b, the mentee’s resistance necessitates an increase in the mentor skill applied. Despite the increase in mentor skill, the mentee resistance does not change and the feedback situation becomes increasingly complex, as reflected by the increasing diameter of the bubbles. Eventually, the mentor resolves the present feedback session by increasing the stakes through presentation of an ultimatum to the student, who then acquiesces.

The SR Soundboard may be used to capture an individual feedback encounter or to capture feedback encounters over time.  This approach allows educators from multiple health science disciplines to track personal and professional development competency domains related to feedback across the dimensions of significance of the issue (i.e., low to high stakes), trainee receptivity, and situational complexity in order to determine the corresponding level of educator skill required to deliver effective feedback.  Feedback from our session participants indicates that the visualization of a feedback session that is offered by this model is highly useful.  Research is needed to determine the feasibility of adopting these tools among academic educators and community educators.

References

  1. Moss HA, Derman PB, Clement RC.  Medical student perspective:  Working toward specific and actionable clinical clerkship feedback.  Med Teach 2012; 34(8): 665-667.
  2. Hewson MG, Little ML.  Giving feedback in medical education: Verification of recommended techniques.  J Gen Intern Med 1998; 13:111–116.
  3. Ramani S, Krackov SK: Twelve tips for giving feedback effectively in the clinical environment. Med Teach 2012; 34:787–791.
  4. Sonthisombat P.  Pharmacy student and preceptor perceptions of preceptor teaching behaviors.  Am J Pharm Educ 2008; 72(5): 110.
  5. Straus SE and Sackett DL. Mentorship in Academic Medicine.  Hoboken, NJ: Wiley Blackwell; 2014.
  6. Murdoch-Eaton D, Sargeant J.  Maturational differences in undergraduate medical students’ perceptions about feedback.  Med Educ 2012; 46(7): 711-721.
  7. Young S, Voss SS, Cantrell M, Shaw R.  Factors associated with students’ perception of preceptor excellence.  Am J Pharm Educ 2014; 78(3): 53.


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A Soundboard Approach to Facilitate Effective Feedback to Health Professions Trainees by Timothy W. Farrell, MD, AGSF, Gretchen Case, PhD, MA, Sue Cantarini, DNP, RN, CHSE, Maija Holsti, MD, MPH, Harriet W. Hopf, MD, Janet Iwasa, PhD & Kristen A. Keefe, PhD