The Art and Science of Learning, Teaching, and Delivering Feedback in Psychosomatic Medicine

Psychosomatics 2015:]:]]]–]]]

& 2015 The Academy of Psychosomatic Medicine Published by Elsevier Inc. All rights reserved.

Perspective The Art and Science of Learning, Teaching, and Delivering Feedback in Psychosomatic Medicine Hermioni N. Lokko, M.D., M.P.P., Jennifer R. Gatchel, M.D., Ph.D., Madeleine A. Becker, M.D., Theodore A. Stern, M.D.

Background: The teaching and learning of psychosomatic medicine has evolved with the better understanding of effective teaching methods and feedback delivery in medicine and psychiatry. Objectives: We sought to review the variety of teaching methods used in psychosomatic medicine, to present principles of adult learning (and how these theories can be applied to students of psychosomatic medicine), and to discuss the role of effective feedback delivery in the process of teaching and learning psychosomatic medicine. Methods: In addition to drawing on the clinical and teaching experiences of the authors of the paper, we reviewed the literature on teaching methods, adult learning theories, and effective feedback delivery methods in medicine to draw parallels for psychosomatic medicine education. Results: We provide a review of teaching methods that have been employed to teach

psychosomatic medicine over the past few decades. We outline examples of educational methods using the affective, behavioral, and cognitive domains. We provide examples of learning styles together with the principles of adult learning theory and how they can be applied to psychosomatic medicine learners. We discuss barriers to feedback delivery and offer suggestions as to how to give feedback to trainees on a psychosomatic medicine service. Conclusions: The art of teaching psychosomatic medicine is dynamic and will continue to evolve with advances in the field. Psychosomatic medicine educators must familiarize themselves with learning domains, learning styles, and principles of adult learning in order to be impactful. Effective feedback delivery methods are critical to fostering a robust learning environment for psychosomatic medicine. (Psychosomatics 2015; ]:]]]–]]])

INTRODUCTION

and psychiatry have advanced over the past century, psychosomatic medicine has evolved into an interdisciplinary medical field. This (coupled with our increased awareness of how adults learn) required

Efforts to understand the relationships between disease and emotion (which form the foundation for psychosomatic medicine) started in medieval times, as physicians explored the emotional problems displayed by the physically ill. Subsequently, physicians (including Sigmund Freud and Franz Alexander) in the 20th century expanded both our knowledge and understanding of how the mind and body are interrelated1; however, little literature on this interface existed and teaching relied heavily on experiential learning, role modeling, and the apprenticeship model. As medicine Psychosomatics ]:], ] 2015

Received July 25, 2015; revised August 28, 2015; accepted August 31, 2015. From Psychiatry, Massachusetts General Hospital, Boston, MA (HNL, TAS); Psychiatry, McLean Hospital, Belmont, MA (JRG); Psychiatry, Thomas Jefferson University Hospital, Philadelphia, PA (MAB). Send correspondence and reprint requests to Hermioni N. Lokko, M.D., M.P.P., Psychiatry, Massachusetts General Hospital, Boston, MA; e-mail: [email protected] & 2015 The Academy of Psychosomatic Medicine Published by Elsevier Inc. All rights reserved.

www.psychosomaticsjournal.org

1

The Art and Science of Learning, Teaching, and Delivering Feedback teaching and learning about psychosomatic medicine to incorporate a wide range of educational methods (where learners increasingly took ownership of the content of teaching) and strategies for delivering feedback continued to develop.2 In this article, we review the ways in which psychosomatic medicine has been taught (placed in the context of teaching theories), present principles of adult learning (and how these theories can be applied to students of psychosomatic medicine), and discuss the role of effective feedback delivery in the process of teaching and learning. HOW HAS PSYCHOSOMATIC MEDICINE BEEN TAUGHT? Teaching methods3 (including role modeling, the use of Socratic questioning, reading, lecturing, participating in case discussions, and role-playing) for education about psychosomatic medicine (as in all fields of medicine) have become diversified and multimodal. In an era before books and peer-reviewed publications related to psychosomatic medicine became readily accessible, teaching was largely based on the philosophy of “see one, do one, and teach one.” More experienced teachers of psychosomatic medicine saw patients with trainees and modeled history taking and examinations at the bedside; these efforts were followed by discussions of treatment strategies, held in the presence of the patient or in close proximity to the patient. As trainees witnessed more evaluations, they practiced what they learned and received feedback from an experienced physician who had been watching the encounter. Over time, trainees were given more independence and saw patients on their own, after which they discussed their findings, impressions, and treatment plans with their supervisors. This type of training/role modeling (still used as a primary teaching method) is most effective when teachers make their expectations about knowledge, competence, and skills explicit. For example, explaining and reviewing the techniques of motivational interviewing (using open-ended questions, affirmations, reflective listening, and summaries) before conducting an interview with a substance-abusing patient helps to prepare and guide a learner in real time rather than by expecting the learner to master the techniques solely by observing. Use of Socratic questioning has been a key component of experiential teaching and learning.4 2

www.psychosomaticsjournal.org

In a supportive, respectful, nonjudgmental, and safe environment, Socratic teaching has facilitated learning by challenging learners to explain their thought process, the evidence for clinical decision-making, and their rationale for treatment planning. As physicians have increasingly written about psychosomatic medicine (e.g., in peer-reviewed journal articles and textbooks), readings have been recommended for trainees.5 There are multiple excellent and comprehensive textbooks that are recommended as resources for hospital-based psychiatry practice.6–8 Reading about specific topics relevant to real clinical cases facilitates case-based learning. Lectures have also been used to teach about psychosomatic medicine. However, the style and format of lectures has evolved (e.g., from teachers reading to learners, to supporting talks with writings on chalk boards or white boards, to using Power Point presentations). Although lectures tend to be a passive learning experience, engagement with the speaker and the material can be enhanced by having clear objectives for case discussions and by employing problem-solving exercises or audience response systems. Lectures are increasingly viewed as more effective when they are focused and brief, as most adult learners lose attention after several minutes. Use of flipped classrooms (e.g., where students read about a subject ahead of time and focus on a problematic area with the preceptor) is also an effective way of learning psychosomatic medicine. Discussions of recently experienced challenging cases or clinical questions also facilitate learning, especially when trainees formulate the learning objectives based on reflection and self-assessment of their knowledge deficits. Such case discussions can occur in a variety of situations (e.g., outside a patient’s room, in hallways, in an office, or in a conference room) depending on the length of the discussion and the need for privacy. Role-playing allows learners to hone their skills with one another and with experienced physicians. For example, a trainee can prepare for a confrontation with a difficult patient by simulating the encounter with an attending (who provides both guidance and feedback) before actually talking with the patient. Clinical cases can be presented by both teachers and learners in a variety of group settings; however, the setting is best determined by the logistics of the clinical situation. As role-playing is usually problem-centered and provides immediate feedback, it enhances learning. Psychosomatics ]:], ] 2015

Lokko et al. TABLE 1.

Principles of Adult Learning and Their Application to Teaching About Psychosomatic Medicine

Principles of adult learning

Application to teaching Psychosomatic Medicine

Adults are independent, self-directing, and need to take responsibility for their learning.

Teachers should empower their trainees to take responsibility for their own learning. This can be accomplished by frequent use of self-assessment exercises (e.g., milestones or learning objectives), which can inform teaching sessions. Trainees should also be encouraged to prepare brief teaching materials to solidify concepts in psychosomatic medicine for residents and medical students. Adults bring accumulated life experiences to the Teachers should begin teaching sessions by acknowledging the experience that learning environment. trainees bring to the learning environment.12,13 Learning that recognizes the prior knowledge of learners and exposes inconsistencies between their current understanding of an issue and new experiences.4,14 This can be incorporated into case discussions where all learners are asked to share impressions of their patient encounters that highlight specific concepts. Adults value learning that is applicable to their daily Teachers should emphasize the learning objectives, either at the beginning or at the needs. end of any learning experience. Trainees are more engaged if they know why they should be learning something or what the consequences of not knowing might be. Adults are task-oriented and more interested in Teachers can organize the content to be taught around problems rather than topics. problem-based approaches. Clinical cases and anecdotes (especially those generated by learners) are more engaging. Adults learn best in safe and supportive Teachers should create a culture of learning (e.g., safe and nonjudgmental) as they environments. build a foundation for learning. Emphasizing that teachers are facilitators of learning rather than transmitters of knowledge fosters learning.

HOW CAN CURRENT PRACTICES BE TAILORED TO ADULT LEARNERS? Effective teachers and educators have a deep understanding of how their trainees learn best.9 Assumptions about how adults learn are embodied in “adult learning theory,” also referred to as andragogy.10 Although andragogy arose in the 1950s, Malcolm Knowles introduced it as a theory of “the art and science of helping adults learn” in the 1970s.11 Andragogy identified learning as a process that promoted problem-based learning and collaborative learning (increasing the equality between teacher and learner).10 Knowles’ assumptions (i.e., adults are selfdriven and self-directing; adults bring accumulated life experiences and knowledge to the learning experience; adults value learning that is relevant, practical, and applicable to their daily needs; adults are task-oriented and more interested in problem-based approaches

TABLE 2.

than subject-centered ones; and, adults like to be respected and learn best in environments where they feel safe expressing themselves) form the foundation of adult learning. Table 1 summarizes Knowles’ assumptions about adult learning and how these principles can be applied to teaching about psychosomatic medicine. Effective teachers understand the learning domains and styles of their learners in addition to the principles of learning emphasized by Knowles. Adults learn best in environments that attend to affect, behavior, and cognition. The affective domain touches upon the attitudes and beliefs that surround the content of what is being taught (i.e., emotional valence promotes learning).15 The behavioral domain covers the practical applications of the materials being taught. The cognitive domain conveys the knowledge or subject matter being taught. Examples of activities and educational methods that form the foundation for

Examples of Educational Methods or Activities Regarding the ABCs of Adult Learning

Affective

Behavioral

Cognitive

Role modeling Use of standardized patients Clarification exercises Use of group process Use of consensus-seeking activities Reflective exercises

Role-playing Simulations Teach-back exercises Role modeling Demonstrations Real-life experiences

Discussions Brainstorming activities Readings Lectures Learning projects Programmed learning

Psychosomatics ]:], ] 2015

www.psychosomaticsjournal.org

3

The Art and Science of Learning, Teaching, and Delivering Feedback TABLE 3.

Examples of Teaching Methods That Appeal to Visual, Auditory, and Kinesthetic Learners

Visual

Auditory

Kinesthetic

Videos/slides Flip charts Diagrams Demonstrations

Lectures Case discussions Informal conversations Brainstorming sessions

Simulations Role-playing Practice demonstrations Writing/note-taking exercises

the learning domains (affective, behavioral, and cognitive) are outlined in Table 2. The primary learning styles used by adult learners are visual, auditory, and kinesthetic.16 Although most adults have a dominant learning style, all 3 learning styles can be employed. Having knowledge of these learning styles can help teachers tailor their teaching tactics to their learners. Educators should aim to incorporate a variety of styles when working with diverse groups of trainees. Adults tend to remember approximately 10% of what they see, 30%–40% of what they see and hear, and approximately 90% of what they see, hear, and do.17 Table 3 highlights teaching methods that appeal to different learning styles. Visual learners learn by seeing (e.g., facial expressions and body language); they appreciate visual displays (e.g., the use of chalk or white boards, videos, diagrams, charts, and images) and demonstrations of concepts. Active note taking helps them to crystalize the information they hear. Auditory learners absorb information by listening. They use voice tone, pitch, prosody, and other speech nuances to make meaning of the information they hear. Audio materials (e.g., tape-recorded lectures), discussions, and brainstorming activities are teaching methods that are appealing to auditory learners. Kinesthetic learners absorb information by doing (e.g., simulations, role-plays, demonstrations, and experiential learning activities); for example, asking kinesthetic learners to lead a simulation or role-play would keep them more engaged. Recent studies on successful learning have shown that information can be retained better when learners practice retrieving newly-learned materials by selfquizzing (to expose gaps in knowledge to guide learning) instead of re-reading the material18 (which creates the illusion of mastery). Adequate spacing of the self-quizzing facilitates deeper learning as learned information is retrieved from long-term memory.19 The application of concepts learned to solve problems 4

www.psychosomaticsjournal.org

promotes successful learning.20 Routine reflections and summarization of materials learned reinforce learning through retrieval and elaboration of the information.21 For example, trainees who reflect frequently on clinical cases and who explain what they have learned to other residents or medical students retain their knowledge of concepts better than trainees who fail to reflect on their work. HOW CAN THE PRINCIPLES OF ADULT LEARNING BE INCORPORATED INTO TEACHING ROUNDS AND BEDSIDE CONSULTATIONS? Teaching rounds and bedside consultations are core clinical and educational activities in psychosomatic medicine. Therefore, it is essential to consider how principles of adult learning can be incorporated into these activities to maximize effective learning. Here, first focusing on teaching rounds and then on bedside consultations, we propose ways by which this may be accomplished. Teaching rounds serve multiple purposes in the education of trainees. They help trainees learn how to precisely present cases and to hone interviewing skills, create differential diagnoses, develop a biopsychosocial formulation, and plan and implement effective treatment.22 Teaching rounds also help trainees to develop skills in autognosis (self-knowledge) and awareness of one’s nature, abilities, limitations, and motivations. As such, teaching rounds can serve as an avenue for trainees to become more confident in the role of a consultant, to foster engagement in case discussions, to promote curiosity, and to solidify the principles of lifelong learning, while expanding the knowledge base of trainees. Defining the objectives of clinical teachers and trainees at the outset maximizes the efficacy of rounds.22 Placing the objectives of teaching rounds into the framework of affective, behavioral, and cognitive domains facilitates learning. Integrating these learning principles into teaching rounds using a variety of Psychosomatics ]:], ] 2015

Lokko et al. techniques (e.g., employing a Socratic method to guide discussions, incorporating humor as well as individual and group reflection, posing questions that foster a sense of responsibility and mastery, exploring gaps in knowledge, and incorporating real-time feedback) increases the effectiveness of visual, auditory, and kinesthetic learning. With affective domains in mind, teachers can promote a trainee’s autognostic skills and psychodynamically-informed understanding of interactions with patients and other clinicians. By using a clinical case as a starting point, clinician-teachers can focus discussions not only on the clinical content of the case but also on the emotional reaction of trainees. For example, the leader of rounds might make a thoughtful and nonjudgmental observation of a trainee or of the group such as “I noticed you rapidly tapped your pen and cringed whenever you talked about following up with the patient” or “I noticed no one made direct eye contact with you when we discussed approaching this medicine team.” Such approaches can facilitate exploration of transference and countertransference and consultant-consultee relationships. Collaborative discussions can encourage trainees to make similar observations of each other, while posing hypothetical and open-ended questions such as: “What do you think the patient wants?”, “What do you think this patient needs?”, or “Why do you think this team called for a psychiatric consultation?” Clinical cases can also serve as a starting point for developing behavioral and cognitive learning principles during teaching rounds. Trainees may be asked to role-play an interaction, either real or hypothetical, between a consultant and a patient or between a consultant and other members of the clinical staff, after hearing about a case. This kinesthetic teaching style can be accompanied by group brainstorming or creation of a written differential diagnosis or flowcharts (auditory and verbal learning) or both. Behavioral learning can also be accomplished through simulations performed by teachers or trainees during rounds, including demonstrations of interviews, psychotherapeutic techniques, or examination skills. For example, a teacher might demonstrate on a team member the examination for catatonia, or a trainee may be asked to do this while other members of the group provide input. Similarly, other aspects of the neurological and cognitive examination can be modeled in rounds or demonstrated through the use of Psychosomatics ]:], ] 2015

videos of clinical encounters with patients having specific examination findings, such as a Parkinsonian tremor, ophthalmoplegia, or expressive aphasia. Brief psychotherapeutic interventions can also be observed through demonstrations, or use of role-playing and video. These might include initiation of motivational interviewing techniques for a patient with an opiate use disorder and intravenous drug use admitted with an abscess, or use of the psychodynamic life narrative to target depression in a patient with physical illness. In this latter therapeutic maneuver described by Viederman and Perry,23 a patient is presented with a narrative that describes the “psychodynamic logic of his depression” by placing his physical illness and depression in the context of his life trajectory of personality, strengths, and coping mechanisms. Observing and implementing this technique can optimize learning in teaching rounds by integrating behavior-learning principles. In a similar manner, principles of cognitive learning can be developed using a Socratic rather than a directive approach that promotes critical thinking, curiosity, and scholarship rather than rote memorization. The leader of rounds can refine questions and observations; for example, if a trainee asks about the pupillary size of a pregnant patient with diarrhea, rhinorrhea, and myalgias, he or she can be guided by the teacher to ask a more targeted question or observation: “I am concerned about opiate withdrawal in this patient, and want to know what the size of her pupils was during the exam.” followed by, “What else should we consider or do we need to know?” Finally, when information is missing or the boundaries of knowledge are reached, learners can be encouraged to perform a focused literature search during rounds; such a strategy integrates active learning into the case discussion, keeping all learners engaged, while working collaboratively. In the aforementioned example, the group might generate a list of signs and symptoms associated with opiate withdrawal while a member performs a real-time literature search on the presentation and management of opiate withdrawal during pregnancy. In addition to teaching rounds, bedside consultations provide a unique opportunity for high-effect learning. They allow an avenue for teaching about the importance of the history and examination skills while also honing in on and exemplifying professionalism, humanism, and affective communication.24 Such www.psychosomaticsjournal.org

5

The Art and Science of Learning, Teaching, and Delivering Feedback activities tap into skills that cannot be taught easily in a classroom setting. Indeed, unlike didactics or teaching rounds, bedside teaching promotes the association of prior knowledge with real-time clinical encounters and feedback. It can incorporate visual, auditory, and kinesthetic learning styles. In the words of Sir William Osler, “to study the phenomenon of disease without books is to sail an unchartered sea while to study books without patients is not to go to sea at all.”25 Bedside teaching compromises only approximately 25% of all clinical teaching in the United States (across all specialties) and varies widely in how compelling and effective it is for learners.26 Some obstacles to bedside teaching include the lack of guidelines for effective teaching practices, particularly within psychiatry, rendering it unstructured and at times daunting for learners, teachers, and patients. Many strategies to enhance the efficacy of bedside teaching have been described.24 We propose that adoption of similar principles, in conjunction with the affective, behavioral, and cognitive learning domains, can provide a framework for effective teaching during bedside consultations, which involve a team of trainees with varying levels of experience. Some of these overarching principles include keeping bedside rounds both learner centered and patient centered, adapting and adjusting rounds to the comfort and expertise of trainees, and taking advantage of “teachable moments” to provide real-time learning and feedback.24 These strategies can be broken down into prebedside encounters, bedside encounters, and postbedside encounters. During the pre-encounter phase, teachers orient learners to the encounter and obtain their engagement or “buy-in.” A set of learning objectives is elicited from the team of trainees, and the team is oriented to the exercise by establishing organizing principles for the encounter. These include defining a time frame, reviewing expectations, assigning specific (active) roles for each team member, reviewing a “game plan” for the encounter, as well as a set of ground rules. These ground rules might include reinforcing an expectation for collaborative care rather than embarking on a hierarchical discussion and reviewing ways by which a patient’s potential agitation or affective dysregulation might be managed during the interview. Although each team member is assigned a role, during initial bedside consultation teaching, the teacher may take more of an active role with roles assigned based on the 6

www.psychosomaticsjournal.org

experience of trainees to keep the entire team engaged. This may include making specific assignments for obtaining elements of the history, performing the mental status or cognitive examination, performing aspects of the neurological examination, looking up laboratory values or inquiries in real time, or developing a differential diagnosis. Given the different levels of expertise often represented on a team, each team member might be assigned roles for the encounter based on his/her current learning objectives, skill and knowledge base, and personal learning goals. For example, a medical student currently learning basic principles of psychiatric examination, history, and diagnosis, might be placed in charge of the mental status examination and the psychiatric history. A psychiatry resident, meanwhile, might review neurological and neuropsychiatric principles, whereas the psychosomatic fellow, currently honing skills of case formulation and brief psychotherapeutic interventions, might be asked to generate a case formulation and present a psychodynamic life narrative after the encounter. During the bedside consultation, the patient is oriented to the experience, while teachers and learners alike may perform modeling, observation, and inquiry. A key step in this process involves discussing with the patient, where possible, what is planned, seeking his/her input throughout the encounter, and at the end, summarizing and providing patient education as well as getting feedback from the patient for the team. The teaching clinician plays a key role in setting the tone for the bedside consultation. He or she avoids lengthy presentations of didactic material and offers demonstration and modeling without “running the show.” He or she also sets the tone for collaborative learning in which the trainees and the patient pose questions. Through direct observation of communication, problem-solving strategies, attitude, and clinical skills, the teaching clinician can “capture teachable moments,” by asking a team member to demonstrate an examination skill (or demonstrating this himself/herself), by asking probing questions of the team, by offering gentle redirection, or by applauding work well done in real time. Although both pre-encounter and bedside phases incorporate behavioral and cognitive learning principles, these can be reinforced, by alignment with affective learning, in the postencounter phase. This critical phase of learning that is performed away from Psychosomatics ]:], ] 2015

Lokko et al. the bedside provides a time-limited debriefing in which trainees can decompress, discuss sensitive or affectively charged aspects of the encounter, as well as the principles of transference and countertransference, while resolving any sources of confusion and asking clarifying questions. Feedback can be discussed not only in trainee performance, but also in “360 degrees.” In this way, the team engages in a discussion of strengths, areas of improvement for future encounters, and teaching goals or roles in need of modification, in a collaborative fashion that keeps learners engaged. Although we present principles for running effective teaching rounds and bedside consultations sequentially, these can be viewed as inter-related learning activities that act synergistically to give rise to the educational program of a psychosomatic medicine service. For example, a model of a typical weekly schedule on a teaching service might look like the following. Tuesday afternoon, 12:30 2:00 PM, teaching rounds: medical students, psychiatry residents, and psychosomatic medicine fellows alternate presenting cases. This includes discussion of differential diagnosis, transference and countertransference, and demonstrations or videos of examination or psychotherapeutic skills and interventions, as well as realtime literature reviews/searches. Roles in rounds during a given week may alternate depending on the skill level and current learning objectives of the trainees at that point in time; for example, medical students present a psychiatric history; psychiatry residents refine skills in performing a brief and targeted literature search and generating a differential diagnosis; psychosomatic medicine fellows refine physical and neurological examination skills, discussion of the psychodynamic principles of a case, and play a role in leading rounds and case discussions. Wednesday morning, 8:00–8:30 AM: the team convenes to discuss the cases on the service and to collaboratively identify a patient for a bedside consultation as well as 1–2 learning objectives for the encounter. The framework, organization, and ground rules for the encounter are discussed and roles are assigned based on the identified learning objectives and the current individual learning goals and skill levels of the trainees. 8:30–9:00 AM: patient encounter; medical student gathers history and performs psychiatric and cognitive examinations, whereas psychosomatic medicine fellow Psychosomatics ]:], ] 2015

generates formulation for the case; attending resident may use a teachable moment to ask a clarifying question, refine a psychodynamic life narrative, or demonstrate an examination skill. 9:00–9:40 AM: postencounter discussion away from the bedside. Team discusses affective, behavioral, and cognitive aspects of the case, reviews learning objectives, and generates feedback for each other and for the encounter. Friday afternoon 1:00–2:30 PM: guided reading or journal club based on trainee-identified topics and learning principle(s) that came up during teaching rounds or the bedside consultation, for example, metaanalysis of management of alcohol withdrawal in patients with medical illness or Viederman’s readings on the psychodynamic life narrative.23 HOW CAN ONE GIVE FEEDBACK TO TRAINEES ON A PSYCHIATRIC CONSULTATION SERVICE? Inpatient psychiatric consultation services typically include learners at different levels of training (e.g., medical students, residents, and fellows). Providing feedback to medical trainees has long been considered an integral activity of education and an essential component to the teaching of medicine.27 Feedback can be brief (less than 5 min) or extensive (15– 30 min).28 Brief feedback is usually unscheduled and provided in the context of everyday work, about a clinical skill or interaction. Extensive feedback is scheduled (typically at the midpoint or at the end of a learning experience) and it can take approximately half an hour to deliver. The “feedback sandwich” (i.e., praise, criticism, and praise) has been employed by many as a way to deliver feedback in medical education as beginning and ending with praise builds trust and increases receptivity of negative comments.29,30 Critics of this feedback sandwich technique have pointed out that praise and positive comments can water down the primary goals (includes sharing information and calibration of self-assessment) of the feedback.30,31 Another technique employed by medical educators for delivery feedback is the “Ask, Tell, Ask” feedback technique that entails asking learners to assess their performance first (e.g., what went well with the patient interview and what could you have done better?), telling learners what was observed during a clinical intervention using specific observed www.psychosomaticsjournal.org

7

The Art and Science of Learning, Teaching, and Delivering Feedback behaviors, giving feedback on self-assessment, and finally asking about learners understanding of recommendations for improvements.31 The “Ask, Tell, Ask” feedback delivery technique serves as a tool for selfreflection and discussion of a learner’s performance that can be further tailored to the milestones learners have achieved to effectively set performance goals for future practice. High-quality feedback (regardless of approach) should ideally be Specific, Thoughtful, Actionable, and Timely (using the mnemonic STAT).32 WHAT ARE THE BARRIERS TO PROVIDING EFFECTIVE FEEDBACK? Although providing feedback and assessment to medical trainees is essential, the manner in which this process is performed is often suboptimal27,33; it often provides little insight into the trainees’ performance. Multiple studies have shown that the quality of oral and written feedbacks is often low34,35 and poorly communicated36 in part because clinical faculty at many teaching hospitals are given little, if any, instruction on how to provide feedback to trainees.35–37 Another difficulty is that the delivery of feedback has long been viewed and practiced as a unilateral process by both the learner and the deliverer of feedback33; the hierarchical culture of medicine has tended to support this one-way flow of communication.38 When the content delivered is positive, feedback tends to be received well; however, critical comments often generate negative reactions from both the learner and the supervisor. Supervisors often find it more difficult to deliver critical feedback because of their fear that this would elicit a negative reaction.35 They worry that providing genuine feedback may damage the relationship with the trainee and create tension between the trainee and the evaluator. Supervisors also cite the fear of litigation as a reason for not providing negative, formative feedback.39 On the receiving end, trainees may have a negative reaction to the feedback, which may prevent responses that facilitate growth. Further, trainees may avoid seeking feedback, for fear of critical or negative performance evaluation. An unfortunate but common scenario is that the trainee wants to ask questions about things that he or she does not know, yet does not want to appear incompetent.40 8

www.psychosomaticsjournal.org

Other barriers to receiving feedback are time constraints and logistics. In the midst of a busy consultation service, it is often difficult to set aside time for feedback before the end of clinical rotations. By the end of the rotation, the opportunity for trainees to practice skills is inadequate. Because of these logistical difficulties, feedback may be provided dayto-day, during the daily course of rounds, e.g., during or after presentations. However, when feedback is provided informally or at unscheduled times, trainees may not recognize that they are being provided with feedback, and subsequently deny that it was provided,33 if it was not explicitly labeled as such. WHAT ARE THE BENEFITS OF DELIVERING AND RECEIVING GOOD FEEDBACK? Effective feedback reinforces good practices, corrects poor performance, and provides a path for improvement.37 Feedback should be “formative” rather than summative and should be directed toward enhancing the students’ ability to modify and improve their performance over time as well as to meet objectives.41 Both the process of communicating feedback and the quality of the feedback are important. With this in mind, we have compiled some guidelines for delivering effective feedback. Feedback is most effective when goals and objectives are shared and understood at the beginning of each new rotation. Orienting the learner to the logistics and expectations of the clinical rotation is an essential first step in being able to assess trainees fairly.24 This discussion should also include a requirement by the trainee to actively seek feedback as well as an expectation that feedback would be provided at specific time intervals.37,41 Both the teacher and trainee should expect that feedback would be part of the experience on the rotation, so that it can be viewed as an everyday component of the relationship.37 Feedback should also occur close to the timing of the clinical experience. This allows adequate time to improve skills during the clinical experience. This can be difficult in the midst of a busy consultation service; however, timely feedback can be brief, and can assure that more formal feedback would occur at specific time intervals as a priority for both the supervisor and trainee.24,35,41 Feedback should be labeled as occurring. Unless this is clearly stated, trainees may not recognize that Psychosomatics ]:], ] 2015

Lokko et al. they are being provided with feedback,41 especially when it is provided during teaching rounds. Feedback on persistent problems should be provided in a private setting and should be scheduled.41 Feedback should be provided also about specific behaviors, rather than about general performance, especially when delivering critical feedback. This assures that comments are based on a specific action, that actions are remediable, and that they can be improved upon.35,42 When an error is made, one should show how to do it correctly.41 Likewise, exemplary behavior should be acknowledged and reinforced.24 Feedback should be balanced and should promote self-reflection. Organizing feedback as a conversation, rather than a 1-way exchange of information can be very helpful.24 Teachers should explicitly seek trainees’ own perceptions of their performance and what they could do to improve. For example, one might ask, “What do you think was a challenge for you? What clinical skills need the most development?” This style often introduces problematic areas that the supervisor had planned to address.24 This tactic also helps trainees develop self-assessment skills that are important for autonomous practice (i.e., without supervision).37 Feedback should also include an action plan, including a discussion about how the learners can improve their skills.24,37 Including suggestions for improvement is an important component of improving the trainees performance.35 Finally, students, residents, fellows, and faculty should share a mutual respect. Faculty should constantly take into account the level of learner they are teaching, and keep expectations realistic to this level. Faculty should also keep in mind that their role is to teach by example. The interactions that trainees see on the service actively influence their choice of subspecialty. Faculty should be aware that they are significant role models for their trainees.41

SUMMARY Psychosomatic medicine (together with how it is taught and learned) is dynamic and it continues to evolve with advances in science and medicine. We have reviewed a variety of teaching methods (including Socratic questioning, reading, lecturing, and role modeling), which have been employed to teach psychosomatic medicine over time. We have emphasized that the efficacy of a teaching method relies heavily on learners and that educators have to tailor their teaching methods to a diverse group of learners while taking into account the principles of adult learning. Effective teachers of psychosomatic medicine must also familiarize themselves with the various learning domains (affect, behavior, and cognition) and learning styles (visual, auditory, and kinesthetic), which promote adult learning among a diverse group of trainees. With teaching rounds and bedside consultations being core clinical activities, it is essential for psychosomatic medicine educators to structure and inform rounds and bedside consultations with effective teaching methods and a variety of learning domains and learning styles. We discussed effective feedback delivery (and barriers to providing feedback) in the teaching and learning of psychosomatic medicine while echoing Ende’s warning that “without feedback mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved empirically or not at all.”27 The factors we have discussed need to be considered for the art and science of learning, teaching, and delivering feedback in psychosomatic medicine and we recognize that educators should be equipped with (and trained in) the tools they need to be effective teachers. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.

References 1. Medicine UNLo. Psychosomatic Medicine: “The Puzzling Leap.” Emotions and Disease; 2012. 〈http://www.nlm.nih. gov/exhibition/emotions/psychosomatic.html〉. Accessed 05/22/15. 2. Fava GA, Sonino N: Psychosomatic medicine. Int J Clin Pract 2010; 64(8):1155–1161

Psychosomatics ]:], ] 2015

3. Cole KA, Barker LR, Kolodner K, Williamson P, Wright SM, Kern DE: Faculty development in teaching skills: an intensive longitudinal model. Acad Med 2004; 79(5):469–480 4. Metcalfe J, Kornell N: Principles of cognitive science in education: the effects of generation, errors, and feedback. Psychon Bull Rev 2007; 14(2):225–229

www.psychosomaticsjournal.org

9

The Art and Science of Learning, Teaching, and Delivering Feedback 5. Nisavic M, Shuster JL, Gitlin D, Worley L, Stern TA: Readings on psychosomatic medicine: survey of resources for trainees. Psychosomatics 2015; 56(4):319–328 6. Stern TA: Massachusetts General Hospital Handbook of General Hospital Psychiatry. Philadelphia: Saunders/Elsevier; 2010 7. Blumenfield M, Tiamson-Kassab M, Blumenfield M: Psychosomatic Medicine: A Practical Guide. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009 8. Levenson JL: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill. Washington, DC: American Psychiatric Pub; 2011 9. Lieb S: Principles of Adult Learning. Arizona: Arizona Department of Health Services; 1991 10. Kaufman DM: Applying educational theory in practice. Br Med J 2003; 326(7382):213–216 11. Noor NM, Harun J, Aris B: Andragogy and pedagogy learning model preference among undergraduate students. Procedia Soci Behav Sci 2012; 56:673–678 12. Pellegrino JW, Bransford JD, Donovan MS: How People Learn: Bridging Research and Practice. National Academies Press; 1999 13. Lionni L: Fish is Fish. New York: Pantheon Books; 1970 14. Haak DC, HilleRisLambers J, Pitre E, Freeman S: Increased structure and active learning reduce the achievement gap in introductory biology. Science 2011; 332 (6034):1213–1216 15. Kort B, Reilly R, Picard RW: An Affective Model of Interplay Between Emotions and Learning: Reengineering Educational Pedagogy-Building a Learning Companion. Paper presented at: Advanced Learning Technologies, IEEE International Conference on 2001. 16. Pashler H, McDaniel M, Rohrer D, Bjork R: Learning styles concepts and evidence. 2008;9(3):105–119 [Psychological science in the public interest] 17. Glaser R: Education and Thinking: The Role of Knowledge. Pennsylvania: University of Pittsburg, Learning Research and Development Center; 1983 18. Karpicke JD, Roediger HL 3rd: The critical importance of retrieval for learning. Science 2008; 319(5865):966–968 19. Arnold KM, McDermott KB: Test-potentiated learning: distinguishing between direct and indirect effects of tests. J Exp Psychol Learn Mem Cogn 2013; 39(3):940–945 20. Casale MB, Roeder JL, Ashby FG: Analogical transfer in perceptual categorization. Mem Cognit 2012; 40(3):434–449 21. Thiede KW, Dunlosky J, Griffin TD, Wiley J: Understanding the delayed-keyword effect on metacomprehension accuracy. J Exp Psychol Learn Mem Cogn 2005; 31 (6):1267–1280 22. Wei MH, Querques J, Stern TA: Teaching trainees about the practice of consultation-liaison psychiatry in the general hospital. Psychiatr Clin North Am 2011; 34(3):689–707 23. Viederman M, Perry SW 3rd: Use of a psychodynamic life narrative in the treatment of depression in the physically ill. Gen Hosp Psychiatry 1980; 2(3):177–185

10

www.psychosomaticsjournal.org

24. Ramani S: Twelve tips to improve bedside teaching. Med Teach 2003; 25(2):112–115 25. Murray TJ: Read any good books lately? Mcgill J Med 2009; 12(1):90–91 26. Gonzalo JD, Chuang CH, Huang G, Smith C: The return of bedside rounds: an educational intervention. J Gen Intern Med 2010; 25(8):792–798 27. Ende J: Feedback in clinical medical education. J Am Med A 1983; 250(6):777–781 28. Branch WT Jr., Paranjape A: Feedback and reflection: teaching methods for clinical settings. Acad Med 2002; 77 (12 Pt 1):1185–1188 29. Milan FB, Parish SJ, Reichgott MJ: A model for educational feedback based on clinical communication skills strategies: beyond the feedback sandwich. Teach Learn Med Winter 2006; 18(1):42–47 30. Bienstock JL, Katz NT, Cox SM, Hueppchen N, Erickson S, Puscheck EE: To the point: medical education reviews— providing feedback. Am J Obstet Gynecol 2007; 196(6): 508–513 31. Gifford K, Fall L: The Holy Grail of Feedback.Engaging in Learner-Centered Feedback that Works. San Diego, CA: The Accreditation of Graduate Medical Education Conference; 2015 32. Cooper CPA: Massachusetts General Hospital Faculty Development Seminar: Communication Series: Improving Case Presentations through Effective Feedback for Clinical Faculty. November 7, 2013. 33. Telio S, Ajjawi R, Regehr G: The educational alliance as a framework for reconceptualizing feedback in medical education. Acad Med 2015; 90(5):609–614 34. Jackson JL, Kay C, Jackson WC, Frank M: The quality of written feedback by attendings of internal medicine residents. J Gen Intern Med 2015; 30(7):973–978 35. Anderson PA: Giving feedback on clinical skills: are we starving our young? J Grad Med Educ 2012; 4(2): 154–158 36. Algiraigri AH: Ten tips for receiving feedback effectively in clinical practice. Med Educ Online 2014; 19:25141 37. Cantillon P, Sargeant J: Giving feedback in clinical settings. Br Med J 2008; 337:a1961 38. Krackov SK: Expanding the horizon for feedback. Med Teach 2011; 33(11):873–874 39. Murdoch Eaton D, Cottrell D: Structured teaching methods enhance skill acquisition but not problem-solving abilities: an evaluation of the ‘silent run through. Med Educ 1999; 33 (1):19–23 40. Mann K, van der Vleuten C, Eva K, et al: Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict. Acad Med 2011; 86(9):1120–1127 41. Richardson BK: Feedback. Acad Emerg Med 2004; 11(12): e1–e5 42. Chur-Hansen A, McLean S: On being a supervisor: the importance of feedback and how to give it. Australas Psychiatry 2006; 14(1):67–71

Psychosomatics ]:], ] 2015