NORTHUMBRIA VOCATIONAL TRAINING SCHEME ACTION PACK FOR GIVING AND RECEIVING FEEDBACK
This pack explores tutorial feedback and how it can relate to both curriculum development and end-point appraisal. It contains examples of the forms used by one practice with a registrar attached to them for four months.
In this practice, each teaching session lasts two hours. Of this about half an hour is devoted to “housekeeping”. This involves an exploration of any problematical cases or situations the registrar has seen since the last teaching session which have not been dealt with immediately. About an hour is then devoted to the set topic. Half an hour is allocated at the end for both trainer and registrar to wind down and reflect upon the teaching session prior to evening surgery. When the problematical cases raise serious issues, the trainer and registrar often agree to suspend the set topic, and devote the time to the problem presented. The feedback sheets chosen for this example, relate to just such a situation, where what the registrar thought was a simple question about terminal care revealed to the trainer a need for a deeper study of the subject.
The best forms to use are those developed by the practice and which all those involved in the teaching find easy to use. However they are designed, experience suggests that they are more likely to be used if valued by both trainer and registrar. They have many more uses than just educo-legal…..
CONTENTS:
1. Blank tutorial record form
2. Blank tutorial feedback form
3. Record of one seminar
4. Feedback form from that seminar
5. The results of the mid-attachment review of the curriculum and the forms from the tutorials
6. The structure used for the final tutorial, with the results of the final review of the forms
SEMINAR RECORD FORM
After every teaching session (including ad hoc problem case analysis where appropriate), the trainer takes time to reflect on the session and fills in this form from his perspective. The trainer comments of four aspects of the registrar’s behaviour and then uses free text to describe the areas covered, learning points addressed, evidence for his conclusions and his subjective response to the session. The headings are adapted as befits the situation. Whilst superficially appearing time-consuming, the process of ending a session in this way has several benefits. It creates a clear boundary between teaching and other activities, frees the trainer to consult without worrying about the registrar, helps the ongoing assessment of the registrar’s needs, documents the evidence used to fill in the trainers report for summative assessment and provides the registrar with a focus for reflection on and re-inforcement of the learning. The whole process takes 5-10 minutes once used regularly.
SEMINAR RECORD
SUBJECT: DATE:
Registrar’s preparation:
Registrar’s contribution:
Registrar’s knowledge base:
Registrar’s understanding:
NOTES / COMMENTS ON THE SESSION:
THOUGHTS / FEELINGS:
SEMINAR FEEDBACK FORM
The registrar is given the trainer’s record and asked to fill in this feedback form and return it to the trainer. They are encouraged not to be constrained by the headings, but to use alternatives, including free text, should they wish.
SEMINAR FEEDBACK
HOW DO YOU FEEL ABOUT TODAY’S SESSION:
· Generally
· Specific good points
· Specific bad points
· Presentation
· Relevance to general practice
· Factual content
· Conceptual content
What were the aims and objectives?
Were they explained adequately?
Were they fulfilled?
Are there any areas you wish to explore further?
SEMINAR RECORD EXAMPLE
This is a real example – only the names are fictitious.
SEMINAR RECORD
SUBJECT: cases / terminal care DATE: 21.12.1999
Registrar’s preparation:
Registrar’s contribution:
Registrar’s knowledge base:
Registrar’s understanding:
All appear good
NOTES / COMMENTS ON THE SESSION:
Some bits and pieces as John explores general practice. Feedback from cases subsequently seen by Alan reveals a positive regard from the patients. Two were complex physical +/- emotional problems and not at all easy to sort out.
John encouraged to make up his own mind as to whether to visit or not – err on the side of caution and do not be swayed by old cynics!
Terminal care discussed with regard to Beryl Smith. The need to look, listen, care, display understanding and respect; not get involved in their anger, but rather acknowledge it; and to explore issues when the patient is ready all emphasised. This is necessary for patients, carers and doctors! Above all it is a situation that needs the artistic use of scientifically derived therapeutics and respect for a patient who does not want to talk. We have two roles here – counsellor and physician. Sometimes they are usefully separated.
THOUGHTS / FEELINGS:
I have more exercises to help you explore this field if you want.
Reference: Symptom relief in advanced cancer. Regnard, C.
SEMINAR FEEDBACK EXAMPLE
This is what the registrar said in reply.
SEMINAR FEEDBACK
HOW DO YOU FEEL ABOUT TODAY’S SESSION:
· Generally
We started off with a few simple questions on palliative care and ended up with a very good review of terminal care.
· Specific good points
You took up the ball and extended it well so we thought about what we do with patients terminally ill.
· Specific bad points
Patients die in the end
· Presentation
Excellent
· Relevance to general practice
Related to a case I saw on my last visit.
· Factual content
Good
· Conceptual content
See above
What were the aims and objectives?
Talking about assessment of need for palliative care, patient’s agenda, thoughts and feelings.
Were they explained adequately?
Yes
Were they fulfilled?
Yes
Are there any areas you wish to explore further?
I will look through your reference and get back to you.
MID-POINT CURRICULUM REVIEW
Half way through the attachment, the trainer reviews the registrar’s progress and checks that the curriculum as agreed is being addressed. Once the registrar has settled into the practice, this curriculum is derived from:
1. The registrar’s answers on a confidence rating scale
2. The results of an MCQ undertaken in week 2
3. The practice’s core curriculum: consultation skills, prescribing, referral, note-keeping, evidence-based medicine and audit
4. The skills specified by the trainer’s report for summative assessment
5. Subjects identified at case analysis
At the review, the tutorial records and feedback sheets are compared with the curriculum to identify outstanding areas, and new ones prompted by the review. The review also informs the filling in of the Manchester Rating Scale (reference), helping the trainer fulfil one of the NVTS’ minimum criteria for formative assessment (reference).
Once again, although this seems time consuming, there are gains in efficiency. The education is more efficiently targeted at need. Many of the subjects highlighted can be addressed through reading!
This is what that review of John’s progress highlighted, with the trainer’s suggestions for addressing them. It is noticeable that the areas of study prompted by the review of the tutorial records and feedback sheets are less clinical and relate more to the attitudes of both patient and doctor than those suggested by the MCQ and confidence rating scale. It leads more naturally to an exploration of values and beleifs of both doctor and patient and hence complements other forms of assessment. Both forms of assessment are useful as they shed light on different areas
MID-POINT CURRICULUM REVIEW – JOHN’S CURRICULUM
This is a list of the areas we have, between us, identified that you need to study, and some suggestions as to how to study them. It might seem like a long list, but I feel that it is easily addressed during the next couple of months. Many of the exercises are simple, straightforward, and usually deemed very informative by previous registrars. All the books mentioned are in the practice library. Please read through this list, add to it, comment on it, action it and get back to me when appropriate.
AREA OF STUDY (no particular order) / SUGGESTED METHOD (to be discussed) / COMMENTSAUDIT / Think about what you would like to audit – then discuss practicalities with me / If necessary, we can have a seminar on audit and the skills you will need first
HOW THE PATIENT AFFECTS THE DOCTOR / Keep bringing along cases where you feel uncomfortable – both videoed and non-videoed / (continued study)
NON-MEDICAL PROBLEMS MASQUERADING AS MEDICAL ONES / As above / (continued study)
DEPRESSION / ANXIETY / As above / (continued study)
MOVING FROM GOOD / BAD TO INEXPERIENCED / EXPERIENCED / A change of mind-set needed here / (continued study)
CHECKING PROGRESS / Manchester rating scale / I will explain what this is on Mon
CHECKING OUTCOME / An audit of all the patients you saw in one week, six weeks after you had seen them, comparing the number who have returned to see you and / or another doctor with previous registrars. / I will explain what this is on Monday
CHECKING PRESCRIBING / An audit and case analysis / I will explain what this is on Mon
PRESERVING BOUNDARIES / Keep bringing along cases where you feel uncomfortable – both videoed and non-videoed / (continued study)
BUYING TIME / As above / (continued study)
GENERAL PRACTICE MEDICINE / List what particularly concerns you re both medicine that happens to be in general practice ( e.g. hypertension) and medicine you see nowhere else ( e.g. intertrigo) then read appropriately. Read about the specific problems you have listed, and skim read the rest to identify other areas you need to study / Children:
Child Care (Hugh Jolly)
Paediatric Problems in General Practice (Boyd and Morrell)
Child Care in General Practice (Hart)
Adults:
Clinical Medicine (Kumar and Clark)
Guide for Trainees in General Practice (Fry)
Guidelines
INDEPENDENT PRACTICE / A change of mind-set needed / (continued study)
ULCERS IN RHEUMATOID ARTHRITIS / Read Kumar + Clark from the practice library
STRIAE / As above
NEIGHBOUR’S MONKEY / Read the Inner Consultation by Roger Neighbour
MENTAL HEALTH ACT / Read handout, then look at resources in section 7 of the resource file: “GP and the Law” from the practice library
CLINICAL GOVERNANCE / Read the resource pack “The New NHS” from the practice library then discuss
PCGs / As above
BEREAVEMENT / Discuss at a session soon – bring a case if you have one.
CHILDREN / PSYCHOLOGICAL / DEVELOPMENTAL PROBS / As above / See above for references
OTHER RESOURCES (e.g. HVs) / As above
BROWN / SMITH FAMILY / As above
ANTENATAL CARE / Create your own draft protocol of what you think we should be doing, and why – then discuss / See Guidelines, Lecture notes on Obstetrics (Chamberlain and Pearce) and Notes for the MRCGP (Kaye) as well as your own undergraduate notes
3 CASES / Review them, then discuss
REVIEW OF REFERRALS / Audit
GYNAECOLOGY / Create your own draft protocol of what you think we should be doing, and why – then discuss
SKINS / See CD-ROM in practice library
ENDINGS
The final seminar is always devoted to review, reflection and goodbyes. This is the format used. The trainer reviews all the seminar records and feedback sheets and summarises both content and impressions on a spreadsheet. This is then given, with the cribsheet below, to the registrar before the seminar. The summary is used to inform both the trainer’s report for summative assessment (where appropriate) and the summary appraisal sheet required by the scheme at the end of every attachment. The review usually takes about an hour. This provides the trainer with documentation for educo-legal purposes, and the registrar with a record of their learning. The rewards for this effort are deeply satisfying as the registrar is enabled to see at a glance the depth and breadth of the teaching, as well as the distance travelled with the trainer as their guide – or the justification for your refusal to sign them up.
ENDINGS
Endings are important. So is how they are handled.
Any change involves loss as well as gain.
Summarising some of the subjects we have covered will help re-inforce them, and help you move on. Exactly what you have gained from covering those topics will be personal to you.
If and when we meet in the future we will be different, because progress is a continuum – we all still have areas to move into, including myself.
As a way of ending that also creates a beginning, I propose that at the last session we cover the following:
1. Any bits + pieces – casework; ? others
2. A summary created from the feedback sheets we have given each other (see my enclosed analysis and the official summary appraisal I shall be sending to the scheme)
3. Your thoughts engendered by considering:
Ideas, thoughts, skills, understandings, experiences:
· you already had that have been affirmed / confirmed
· you have learnt
· you now know you have to work on
· how you intend to meet your future needs
4. The future – where are you going, and how are you going to get there?
SEMINAR RECORDS AND FEEDBACK ANALYSIS
This is a list of subjects covered during the attachment. The comments reflect the trainer’s thoughts as he re-read the seminar records and feedback sheets and reflected on them, rather than the literal report of the content of them. It does not cover material read by the registrar after direction by the trainer.
SEMINAR RECORDS AND FEEDBACK ANALYSIS – JOHN SMITH, March 2000
This is a list of the areas we have covered during the seminars. The comments reflect my thoughts as I re-read the seminar records and feedback sheets and reflected on them, rather than a literal report of the content of them. It does not cover material studied by you outside the teaching sessions.
DATE / SUBJECT / COMMENTS6.12.99 to 10.12.99 / Induction and the first cases / Early cases seem fine
16.12.99 / Cases / So general practice is different – very!
21.12.99 / Cases
Terminal care / And complicated – we have different roles in different cases at different times
23.12.99 / Cases
Alcoholism / Though superficially easy, it is a difficult art especially when patients make unattainable demands
28.12.99 / Christmas
30.12.99 / The millennium
4.1.00 / The millennium
7.1.00 / An exhausting day / And sometimes we feel for our patients, sometimes with them, and sometimes because of them
10.1.00 / Time management
Stress management / And we need to be really organised before we can deal with them (patients and our feelings)
14.1.00 / Car parks
Cases / And other people’s unreasonableness (being assertive comes in handy here)
17.1.00 / Cases
Video / And before we can sort out other people’s disorder
21.1.00 / Video case / Beware the retrospectoscope – it always has 20/20 vision
24.1.00 / A weekend debriefed / John increasingly aware of the “other side” of medicine – there always, but seen best in general practice
28.1.00 / Depression / This other side co-exists with and is often indistinguishable from "true medicine"
31.1.00 / Cases
Change theory / This makes life difficult, if exciting
4.2.00 / Holiday
7.2.00 / Holiday
11.2.00 / Cases / Beware the boundary-less patient – another cause of stress
14.2.00 / Cases / Listen to the monkey on your shoulder – he may not be right, but he has a valid opinion!
18.2.00 / Cases
Boundaries / Just as life was getting simpler, along comes: transference, countertransference, projection and reflection. HELP!!
21.2.00 / Cases of potential carcinoma / Key signs and symptoms and how to notice them
25.2.00 / Pauline
Outcomes / A very confused / confusing case – though the global outcome of this consultation seems fine
28.2.00 / Manchester rating scale
Confusion / John is where he is supposed to be
This involves being confused by confusing cases
3.3.00 / Levels of communication / But must be careful about the levels at which he and others are communicating
6.3.00 / Social deprivation / An exploration of a completely different world, I think, for which we need empathy, not sympathy
10.3.00 / Study leave
13.3.00 / Cases, hammers and nails
Prescribing audit / I need a holiday!
John’s levels seem ok!
17.3.00 / PCGs
The changing world / Is everyone else mad but me???
20.3.00 / Trainer holiday
24.3.00 / Trainer holiday
27.3.00 / Cases
Video / Reflections, reflections!
31.3.00 / The end
Overall impression: / Strong emphasis on:
New conditions (simple “kitchen cupboard” medicine)
New complications (psychological / physical interface)
New communication / relationship issues (transferences etc)
What we have not done: / Some of the factual stuff (see mid-point curriculum review – you know what you haven’t read!)
Neighbour – read the Inner Consultation
Enough videoing
SUMMARY APPRAISAL