Hello and welcome. I am Michael Johnson and welcome to this talk called Precepting 101. Happy to be here. Thanks to the course directors and the AANS for educational staff for having me for this important talk. Introduction. Michael Johnson. I am a physician assistant. I am full time faculty at the George Washington University program. I'm an assistant professor here and I hold an assistant professor in the Department of Neurosurgery as well. Views and opinions expressed here don't represent the program or the neurosurgery department. And this presentation was created in collaboration with the GW Center for Faculty Excellence and my esteemed colleague, Dr. D.D. Herman, who I owe deep gratitude for helping develop this this lecture. I'm going to go and turn my camera off. No real reason to look at me this whole time. And then we'll get started with some content. So learning job groups today at the end of this session, I hope you'll be able to identify the benefits and opportunities for precepting APP students. So we're going to talk a bit about why you should, if you should, if you're considering it, if you're on the fence. And then we're going to talk about some adult education techniques to increase your effectiveness as a potential preceptor, if you're thinking about it or you're doing it already. So hopefully some things you can leave there to get better. I think the most important thing to talk about is should you precept? And I'm not here to tell you whether you should or not. I'm not advocating one way or another. I precepted for a long time and it was kind of my gateway to starting an academic. But there's individual reasons. There's reasons to do it and there's reasons not to do it. But some of the benefits you get to give back to your profession, whether it's a nurse practitioner or PA or whether you're a PA precepting NP students or vice versa, we're giving back to the professions which we work. If you have an interest in academia in the future, as I did, it's good to have this on your resume to see if you like teaching. It is a shows commitment to lifelong learning, right? You have to be an effective preceptor. You kind of have to know what you're talking about and be able to answer questions and be able to stay current in the literature and best practices. So I think it is very helpful in my attempts of being someone who appreciates lifelong learning to be a preceptor. It is a way for some organizations to recruit capable new grads. It's kind of a it can be kind of a, let's say, a long job interview, as it were. And you get to look at people who are interested because in neurosurgery almost all the time it would be an elective. So you're getting some some some selection bias of people who are legitimately interested in neurosurgery that you're getting to look at. And you get to, you know, think about having to work with new people. It allows for interprofessional development. PAs can precept MPs is my understanding. And I'm a PA. So MPs can certainly precept PAs, PA students. And one of the things that's been most valuable to me was as a preceptor who is mentoring, mentoring people who have questions, who could benefit from our experiences as experienced people working in the field of what things work for us and helping them look for new jobs and answering questions. People need help. People need mentors. And mentoring is really one of the most important things you can do for younger folks coming up behind you to help them with their job satisfaction and job security. Yeah. So should you precept individual decision, but there are certainly good reasons. Some more kind of more material things is that you can get continuing education credits. So physician assistants who precept PA students are eligible to receive Category 1 CME. And this is a relatively new thing last couple of years. So what the AAPA says is that individual preceptors may be awarded AAPA Category 1 CME at a rate of two credits per student per week with no limit. That's a lot. That's a lot of CME to get for precepting. That's not to say it's not a lot of work, but it's a lot of precepting. Excuse me. A lot of CME. Nurse practitioners who precept would get a letter, particularly from our training academy or training program, noting the amount of hours spent. And that could, in my understanding, be turned into CME as well. There's possibility of program affiliation. So there are perks to this. You can get a clinical or academic appointment, which would open some doors, including library access, which is which is very handy, which I found very handy. My library had all the Greenberg books and all the theme books. So I could go read as much as I want to with my with my with my faculty appointment. It opens you up to faculty development opportunities. So I've taken a screenshot of what we offer here at GW. And I'm not again, not trying to advertise for GW in any way, but this is just to be used as an example of the things that you have access to just by being clinical faculty. All of the teaching tools that are available, all the seminars, all the free CME that you can get access to just by having a clinical appointment. And it kind of gets your foot in the door for you to do other things with service. If you're interested in giving lectures, you can say, you know, I can probably give your neuro trauma lecture. I can give your Degen spine lecture or your neuro lecture because we're all teaching that. So if you want to get involved with the program at another level, this is certainly a way to get your name in other people's email box. But if you're going to get involved, I would check with the program and be very upfront. Hey, I'm going to precept your students. What are you going to do for me? What kind of opportunities, what kind of perks do you have for your preceptors? There are financial incentives, and I'm not here to say one way or another. There are opportunities for payment. Some some programs pay. Some programs pay for all sites. Some just pay for core sites, which an elective would not necessarily count for. There are some programs that are paying, whether or not they pay the organization or the individual. That's a question to ask if you're seeking payment and who gets that money. It goes to your organization. What percentage do you see? There are some tax incentives out there. Don't know too much about them. This is just a copy from something I found on the Interwebs about the Virginia Nursing Preceptor Initiative, where if you are a precepting APRN students that you can get tax incentives. So that would be handy to lower your tax bill. So there are, again, a number of financial incentives for being a preceptor. So what are the requirements for precepting? So in all programs, there's going to be some requirement for a medical license in good standing. And the programs are required to vet you in some way or another to look at your license and your board certifications. There's some degree of variability. What degree of experience do you have in that specialty? Some programs may have said you can't precept until you've been doing that thing for two years. Some are not so much. If you are a nurse practitioner, you should have the correct certification for what you are precepting about. If you are a pediatric nurse practitioner, you probably shouldn't be precepting in adult critical care or something like that. That has to be appropriate for the setting at which you are precepting. They'll have some kind of requirements for hours. You have to be able to say, yes, I can give them a full time experience, which is greater than 36 hours or something like that. How many patient contacts they are expected to see during their time for you or per week or something like that. So there's variables that expect that you'll need a medical license, a board certification. I've heard this a lot, like, how do you find a program? I promise you, PA and NP programs are looking for you. They just don't know how to find you. So if you are interested, just look around. Look who is near you. Look on the interwebs and find an NP program or a PA program in your general vicinity. And sometimes there are plenty of remote opportunities. So you can look where the area you trained, but get on the interwebs and find their clinical coordinator or the director of clinical education. And send them an email and say, look, I'm thinking about precepting. Don't just a conversation doesn't mean you have to say, you know, I may want to get paid. What are your rates? So on and so forth. Have your questions up front. State associations have listservs and you can get connected. I promise you they're looking for you if you were at all interested. So just look around. So. If you find something that you want to do and you want to start as a preceptor, it's very helpful to be up front that you're new to precepting and that you want some resources and you want to be watched a little closely. And they'll do that for you. They'll mentor you because they want to keep you. They're going to invest all of this effort and energy and money into you. They want to keep you on as a preceptor, keep you engaged, keep you happy and keep you coming back. Because the students aren't going to stop coming and we want our students to have a great experience. So we have a responsibility to kind of maintain an excellent relationship and mentor these preceptors and get them comfortable in their role. So tell them you're new up front. You should be asking for the syllabus and that'll include learning outcomes and objectives. And we'll kind of go over what those are. Second, you ask for resources for teaching the clinical learning environment. Like I showed you, my school has a center for faculty excellence. I have tons of lectures and things like that. I can give information on teaching in the clinical learning environment. That's what we call clinicals, teaching, learning and clinical learning environment. Ask early, what does it take to get a faculty appointment that will get me library access? I don't want to pay for world neurosurgery, but I really like to read it sometimes. So I want to get access. I want to do some journal reading. So ask early. Again, you're doing something for them by taking students. They can do something for you by telling you at least what it takes. If they offer it right off the bat. Great. Take advantage of those opportunities and use your library access. There'll be some kind of handbook that has the clinical year handbook or the policies and procedures manual. Just so you know what the students know and their expectations. They'll have things like absences and policies and things like that. Don't get too into the weeds, but it's good to at least look over. Helpful. Look for other ways to get involved in the program that interest you. Teaching in the classroom, doing labs, helping with admissions, looking at CME events. Make sure you're asking early for student feedback so that you can make adjustments for you and for the students and reach out with questions. There will be someone in charge of you, whether it's the elective clerkship director or the director of clinical education. Someone's job is it to make sure that you have the resources you want and you're getting the feedback. So ask for it early to make sure that you're on the right foot and you can get better at correcting mistakes. So just a broad, busy slide here on the difference between outcomes and objectives. Getting into a little bit of the weeds and things that nobody ever taught me until I started as a professor. So outcomes have to do generally with the course, the overall section or course or clerkship. These are broad and related to knowledge or skill should acquire at the end of the course. So there's a long paragraph over an objective. I think it's some syllabus I looked up online of what is covered as an outcome. Whereas objective, objective things are specific to one, generally one particular thing. They are measurable that I can give somebody a test. Can you do the thing that I ask you to do? And they start with some kind of verb, in this case, recognize. So can a student recognize potential contraindications or sequelae, surgical manner of disease commonly encountered in surgery? And can they develop a appropriate health promotion and disease prevention care, blah, blah, blah, blah. So they are specific and measurable, whereas outcomes are broad and general. So you get a syllabus that'll have both of those things. They are a nice jumping off point for what the program expects of you. What do you want the student to learn while you're out on this clerkship? Go to the syllabus, find the objectives. Oh, they want them to do this and they want them to do this and they want them to see this and then perform this technical skill. Those would all be objectives. Starting as a preceptor. So some tips when you have a student, you want to be very clear about goals and expectations. Ideally, the program or the student would reach out to you in that early. And that is your opportunity to kind of lay the groundwork for how you expect this to go. The chances are the program has some rules and that would be in the policies and procedures manual. But it's up to you to kind of set the tone and make sure the student is following the rules. So you are responsible for making sure the time commitment. When do they show up? Where do they show up? How do they dress their technical skills? How they communicate with you, how they communicate with other members of the staff, all of those things. And as you do this, you need to understand where the student is in their clinical training. So clinical year in most programs is one year. So there is a big difference between getting a student on neurosurgery in the first block of the year versus the eighth. Or some programs have 10 blocks that they've had all of this other experience and they've had surgery and they've had ER. And they get to you with a nice rounded out fund of knowledge and some procedure and technical skills and some knowledge about being in the hospital. Versus if they come to you with first block and they've only practiced sewing on silicone and they don't know how to call a consult. So there's a big difference. And you may say to the program, you know, I don't want to precept a student unless they've had surgery already. And that's fine. That was not my way about it. I tried to always meet students where they were. And I was pretty satisfied I could provide a good opportunity. But if that's what you want to do, then you can say that the student won't get much out of the rotation unless they've had some surgery. That's fine, too. But understand where the student is in their clinical training. You want to make sure you orient a student to the facility and the service that whatever level of EMR access they're going to have, they understand. And that's often set by the medical staff office where they have read only or read and write or read and sign different different levels of EMR access. They have access to imaging. Do they have access to the scrub robot? Do they have enough PPE? Do they have access to lead? Do they know where the bathrooms are? Do they know where the workroom is? If there's a sleep room and you're on call, do they know how to access all of those things? You don't want to find out late. They don't have access to all those things. You want to introduce them to everybody on the team, the residents, the other APPs and certainly any physicians you work for. You want to make sure they are aware of safety protocols. They know where to park. Hopefully you're figuring out a way to not make them pay for parking because being a student is expensive enough. They understand how to access security protocols to get them to their car or get them to the bus stop or whatever it is to help keep them safe. Things like that. Other things that you need to kind of make sure that you're aware of is that you have access to any Title IX training, particularly if you're going to be clinical faculty, that you are then now a Title IX reporter. And there are certain expectations of that. So, again, something worthwhile to talk to the program about. OK, so we decided we're going to precept. We got to start teaching now. What does that mean? But first, I want to talk about learning, OK? Learning is a process. It's not a product, right? We can't say this is learning. Learning is a is a process and it's a product that leads to change. And we don't we don't know it's taken place and we have to infer that it's taken place. We've done all the teaching we can and we have to infer that learning has taken place because it only occurs in the mind of the learner. And by definition, that learning is a is a change in behavior, beliefs or behavior, excuse me, knowledge, beliefs, behaviors or attitude. So how do we know that it occurred without without being in the learner's head? Learning takes place over time, has a lasting impact on how learners think and act. And this is something that really resonated with me is that it's not something done to students. Learning is something that students do for themselves. And it's how how students interpret their experiences and how they respond to those experiences. So they have to have new experiences over time that lead to a change in behavior and attitude. So learning is not something done to a person, it's something they've done for themselves. So again, kind of say, you know, I taught them and I taught them, of course they learn. Not necessarily. Learning only happens in their mind and we have to kind of infer and that's why we have them. So there are challenges and I don't pretend that there are not challenges to teaching in the clinical learning environment, teaching in clinicals. So I'm going to go through a bunch of these and then before, I think, before we can talk about how we can enhance teaching and learning, it's it's important to acknowledge that there are some challenges. So what are the things that we hear the most? Not enough time, right? Everybody's busy during the day, of course we don't have enough time. If you're getting newer people, we have to spend time on basics. If we have different learners at the same time, particularly of different levels, you know, you're taking a PA student from this program and also this program and they're on a different calendar, so this person is second block and this person is seventh block, they may have different levels. Say you're getting pop-ins, say you're, you know, teaching nursing practitioner students and they're rotating through a bunch of different sections and you only get them for a day or so, it's hard to gain entrustability with students just popping in for one session at a time. Speaking of entrustability, not knowing what to trust the learners to do. What can you send them to pull that drain? Can you send them to measure the drain? Can you send them to go talk to the family? Those are all things you have to build up the confidence in your learner and build trust over time. Neurosurgery is kind of high-end stuff and so it's it's hard for us to explain in a few minutes before a procedure or a few hours what it is we're doing and so this is just, this is a particular challenge in neurosurgery. Sometimes people see teaching as something done in a classroom on a whiteboard or PowerPoint. I'm sorry here, but yeah, so that's that's a challenge. You know, people just see it that way and people believe that you have to stop doing to teach and so we want to kind of get by some of the barriers and so some of the leaders in medical education, Pratt, Arsenault, Collins, who are kind of big names in literature, have said a big barrier to teaching in the clinical learning environment is seeing teaching as a trade-off with service where workload, the things we do every day, compete for time. But they say this kind of misses the underlying premise, like back from the previous page, that education and service are the same thing and that learning occurs as the work is being conducted, sometimes unconsciously, and that teaching should be a part of the work that is happening and we're going to talk about that in a minute. Okay, so there's some models. There's some models to give us guidance on how to teach in the clinical learning environment and some of these you might recognize or you might have used in the past. So I'm going to talk about a few of these. The one minute preceptor is kind of a handy one and it's typically used after a learner has seen a patient and is outside of the patient room. In the one minute preceptor model, there are five steps. First, give a commitment about what the learner thinks is going on, probe for their reasoning, teach a principle, provide feedback, and lastly, correct any errors or like misconceptions. That's a nice way to go. So ant mini is another common one and it's about pattern recognition, which I think a lot of neurosurgery is about pattern recognition, and it comes from the principle if you see a woman on the street that walks and dresses like your aunt mini, she probably is your aunt mini, even if you can't see her face. So in clinical education, like the learner sees the patient independently, they will present on the main complaint, preceptor diagnosis, the aunt mini, right? And you as the teacher independently go see the patient when the learner is writing the note. After you see the patient, you give learner feedback, make any change in the patient record, even before signing off. So you can look up a few of these. They're somewhat helpful and kind of have similar kind of ideas. And I won't go through too many more of these. So regardless of the model, there are three common steps. And so the first step is identifying the needs of the learner. The second step is teaching according to the learner's specific needs, and then providing, excuse me, providing feedback on their performance. Okay, so the first step is always the same, you got to know the needs of the patient, so you can target, excuse me, not the patient, the student, so you can target their needs, you got to know where they are in their training, you got to know the objectives of the session, you have to know the outcomes for the course, you got to know where the learner is. But the first step is always the same. The second two steps may occur in an iterative fashion, some teaching, giving feedback, then teaching some more and giving feedback depending on the case or situation. And so we, our institution developed the words target, lead, and comment and TLC to kind of make these steps of how we teach in the clinical learning environment, or teach on the fly, because that's kind of what we're talking about doing. We try to make it minimal, TLC, target, lead, comment. And so, you know, unfortunately, like I said, even if you follow these steps, it's possible that no learning will occur despite your best efforts. This process is focused on teaching rather than learning. So there's no guarantee that learning will occur. In order for learning to occur, we must kind of review what's necessary in the learning science literature. So I'm going to get a little bit sciency here with you. So what do you have to have for learning from experience in the workplace? And that's kind of what this is, right? Clinical learning is learning in the workplace. So here's what learning science tells us about how it occurs in the workplace. Much of learning in the workplace is informal. It may be intentional, like teaching around a case, some is incidental, the result of something else, like making a mistake. Some is unconscious, just like being in that environment, you know, students learn how things are done. The triggers to learning are what the teacher does, what the learner does, what others are observed doing and the immediate situation or case. But to learn from experiences, there are four things that are required. Those are the big colored blocks in the middle. Participation, top middle blue, learn must actively be doing something, even if it's just observing for something specific, but they have to be participating. And again, participating can be observing if it's intentional, right? We're going to do this case, it's an endoscopic, but I want you to watch specifically for X, Y and Z, you have to make it specific. Moving to the right, reflection. The learner must reflect on what occurred in the patient encounter and why. This step is essential to promote critical thinking and enhance problem solving, and it stimulates learners kind of self awareness. So as they've had a chance to reflect on what happened, then they have to codify, right? And so what that means, they must form kind of their own theories and their own conclusions about that experience, and what's going to happen in a future situation, and what they may need to do differently, or, or similarly, in a future encounter, they have to change their behavior. And lastly, the learner needs to execute a new action, they need to do the thing based on the codification of what they had reflected on and what they what they saw, right? So they have to participate in something, they have to be given an opportunity, they have to reflect, they have to codify it, they have to decide to change their behavior, and they have to take a new action, right? And then the cycle kind of starts all over again, okay? So we're going to put these together, right? So when we have the best best practices for teaching on the left, identify the needs, which we call targeting, teach rapidly, I got a little typo there, and then we're going to comment. And then we're going to put it together with learning. We're in a combination, we're going to make a combination out of these two approaches for the clinical environment to make it that we can teach on the fly. So teaching and learning on the fly, we have it, we have a new model that we've created, called TED, that shows us the how to teach on the fly. So learning is optimized. Okay. So when we go back to, you know, identifying the learner and where the learner are, so the first step in the model is target. So target the teaching and learning, and to do this, you have to know what the goal is for this educational encounter, right? Why are they with us today? What are we hoping to get out of this? So to determine the goal, you have to give some thought to where the learner is, and what we call the learner's zone of proximal development. And this is important, if you're only going to get a few things out of this lecture, I think this is one of the most important things. So the zone of proximal development is the space between what a learner can do on their own, and what they can only do with expert guidance. Okay. So an example of this, most learners entering the clinical learning environment already know how to take a patient history and conduct a physical exam. That should be a baseline expectation for you as a preceptor. However, some students, development of a differential diagnosis may be a change, right? For these students, the target, the skill just beyond what they can do on their own would be that point, right? Would be creating the differential, but for others, the differential may be a well honed skill. So the focus needs to be pushed a little further in creation of a management plan. So right, we have to know what the learner can do on their own, and what they need help doing with our expert guidance. So sometimes recognizing the best target is challenging, and so kind of here's some ideas to help, you know, find what the target is. First, stop and take a look at the rotation and program requirements. Like have a look at the syllabus, look at the objective, what are they supposed to be able to do while they're with you. Second, use cases that you and the students are currently experiencing. It gives context to the content that, you know, can offer learning opportunities. Also consider where the student is in their training. I've harped on this just a little bit. What have they already experienced? What do they still need to learn at your level? And if you don't know, ask, ask the student, ask the program. You know, good questions. Have you had a chance to do blank? Have you had a chance to prep and drape a patient? Have you had a chance to place a Foley? Have you had a chance to pull a JP drain? Those kinds of things. Ask them about their prior experience, and a great one, and I use this with my kids. What surprised you? That is a great tool to make someone kind of reflect and get an understanding of kind of where they are. What surprised you about your last rotation? What surprised you about this case? What surprised you about something? It's just, it's a nice tool to get a student to reflect, and then ask. What do you want to know? What do you want to know about craniotomies? What do you want to know more about laminectomies? So just ask, and they'll tell you, and you can, that will help you develop your targeting. Second step, teaching on the fly, is to engage the learner, and so learners can be engaged by giving them something to do, or giving something to watch, and I, you know, it's hard to say that just watching a case is enough to engage, but but it is, I promise you it is. So, you know, the obvious answer when told to engage a student is having them do something, but it's really important to put some structure around what they're doing. Put up some scaffolding for them. Tell them what they should do. Tell them under what conditions you'll get involved, or intervene, or intercede, and make sure they understand what to do if something is unclear or unexpected, you know, and then give them an idea what you're gonna discuss with them afterwards. You send them, I want you to go, you think a student is ready, I want you to go pull this drain. You know, you're gonna take it off a suction, and then you're gonna have the tools ready, and you're gonna pull it out, and you're gonna hold pressure, and you're gonna sew it, or not sew it, or whatever it is, and make sure you tell them what to do if something is unclear or unexpected, and it bleeds a lot, or CSF starts coming out, or it gets stuck. You know, those are the kinds of things to tell them what to do. They got to know that so they're confident, and then give them an idea. So the things we're gonna ask about is what did you do with your sharps? What did you do with the bucket? How did the patient tolerate it? Those kinds of things. Tell them what will be discussed after so they're prepared. Sometimes it's not appropriate for the student to actively do something. Maybe it's student's first day on their rotation, and you're about to do a cranium. In this situation, you can say, you can tell the student to watch the procedure rather than having them do it, because maybe it's a trauma cranium, and time is of the essence. But it's helpful to tell them not only what they're watching, but what they should be watching for, right? So you should also tell them what you may ask after the observation in advance, and so they know what to expect. Say, pay close attention to the layers we open, and how we address them in closing. Was this an epidural? Was this a subdural? Why? You know, those kinds of things related to something that you can ask about the case, right? Sometimes you need to combine both active and participation, and active observation to fully engage the learner. So the final step is to teach on the, to teach on the fly, is to discuss. So this is the point at which the student reflects on their learning, and in that they identify what they're going to do with their knowledge and skill, and they're gonna plan future actions, right? So they're getting that reflection, they're getting that codification, and they're going to plan their new actions. So in discussing, here are some questions that are helpful to get the learner to reflect, and then codify, and then plan future actions. So again, back to learner first, and then your comment. So if you want them to reflect on something, what surprised you the most? What happened in that case that surprised you the most? And that really makes people reflect. What does this, you know, if you have them do something, what does this experience suggest to you about your strengths? And they'll say, oh I did a good job holding, you know, the suture for you while you sewed, or I did a good job understanding what the instruments are. How about, what does this suggest about areas you improve on? Oh, I need to improve on my hand tying, I need to, you know, whatever it is. What you might do differently the next time? Oh, next time I'll be more proactive about asking to tie. I think I'm gonna go home and I'm gonna practice. And then what would you do if X occurs? You can give them some odd complication and just something to make them consider when they might ask for help. So codification, again, what, how would you summarize what you took away from this? So making them summarize the case and how they learned, and then what would they like to work on next? And we're talking about action. How do you plan to follow up? Put it in their court. How do you plan to follow up? And then let, again, putting in our court, what can I do to help? Right? Don't just say that you're gonna, you know, what you're gonna do. Make them seek the help to create, excuse me, the action they're gonna use going forward, right? We want to put up the scaffolding, but we want them to be an active participant here. So summary, it's not enough just to think about how you're gonna teach. It's also about knowing how learning occurs. So when you put the best practices for teaching and learning together, this model, this TED, shows how you can kind of teach on the fly in a clinical environment to maximize learning. Remember, just because you have to, because, remember, you first have to target or identify the goal of learning. Then you have to engage the learner by actively participating, and then you have to discuss the encounter with the learner. And so in that final step, it's your job to help the learner reflect, codify, and plan their next action so they can continue their development. Which brings us to one of the hardest part about teaching is giving feedback. It's challenging, it can be uncomfortable, but it's imperative for learning. And so timing, you know, most commonly occurs immediate, but there's value for delayed feedback where students are given the opportunity to fix their own error. It's often coupled with, you know, praise and recognition. And and I'm a coach, and so I coach Little League and soccer and stuff, and I follow the kind of what's considered to be a magic ratio of five to one. Five kind of compliments or praises or even acknowledgments, followed by some constructive feedback. And so when you're giving feedback, it kind of tells learners what they are, or at least you perceive they are and are not understanding, what performance is going well or not as well, and how they should direct subsequent efforts. And I will say, feedback should be explicit, appropriately timed, generally it's immediate, it should be frequent, and it should be honest. So based on the review literature, these are characteristics of effective feedback. One, it's approached as a continuous learning opportunity. Feedback helps the learner get better. It's part of continuous learning. It is based on observation of a focused, agreed upon goal or set of goals. So this is another thing, if you're going to remember a few things today, feedback is goal based. It has to be based on a goal. If the goal is to not tie better, you should be giving feedback on not tying better, right? So you have to have a agreed upon goal or set of goals by which you're going to give feedback. It occurs immediately as possible after the observation, plus or minus. It follows somewhat a structured approach, and it's repeated over time. It's, you know, you should be giving feedback throughout your clerkship or whatever it is you're doing, repeated over time in a structured approach. It engages the trainee with a dialogue. It's not just a session by which you're telling them all the things they're not doing well. It should inspire a dialogue. And it ends, like it began with a agreed upon goal, it ends with specific agreed upon actions so that you can guide their practice and with which you give further feedback. So that's all great. We may agree on the characteristics, but how do we do it, right? Where does it fit in the schedule? How do you safely conduct a feedback session? And how does learning occur from feedback? So here's kind of what the learning science say about feedback, and there's a lot out there. Theory and research suggests that, you know, if you look at the top, practice enables observed performance, so that in turn allows for targeted feedback, and then feedback divides further practice. Makes sense, right? So we have them practice, we observe it, we give them feedback, and then they practice some more. All of this is driven about what's in the middle, the goal, right? The goals direct the nature of the focus practice. They direct the basis for evaluating this observed performance and shape the targeted feedback that guides future effort. So we have this circle around a kind of middle goal here that everything is about the goal. This is goal-directed practice, targeted feedback, and enhances the student's quality of learning. So if not tying is the goal, let them practice, then observe, provide targeted feedback. Well, here's your air knots, not tight enough, too much spacing, post-stand's weak. Let that specific feedback guide further practice and continue to observe, right? Student will improve and approach competence, and that'll allow you to change the goal. Maybe the next is fascia, right? And so better than saying at the end of the week on their feedback, work on hand tying. No, no. Be specific. Be specific. Your sutures are too far apart. You're getting too many air knots. You're not tying enough knots per stitch. Be specific. And then next week, if we can succeed here, I'll let you do some fascia. And then after we do fascia, we'll do whatever's next. So work on, just be more specific. Don't just say work on hand tying. So we put this all together. We come up with a clinical performance development process that kind of looks like this. This process kind of helps us see how deliberate practice on a set goal coupled with targeted feedback fit into clinical competence, how we're making competent clinicians. In this process, we kind of first, again, I hate to drive this home. We set a specific goal or set of goals. We deliver it. We practice. Ideally, we observe this. We allow the trainees to reflect. We provide targeted narrative feedback. And then we work on an action plan together. And then the process keeps repeating for the learner and the teachers as the goals are formed because we're making new goals. Ideally, we're learning new things and getting better. So that will allow us to create new goals. And this starts all over again. So we need to talk feedback a little more in detail. And so when it's time for that narrative feedback, this feedback session, we get the most out of it. The learner is ready for it. It's psychologically safe. It's the best possible environment. So we want to have some kind of guidelines for how to kind of set up a feedback session. So establishing time and location for a feedback session. If you're going to have a session. I'm not saying you have to have a session every time. Like if you're watching them not tie, you can just correct them. You know, particularly if something's unsafe, we expect to correct it as it's happening. But if you have the time, setting up an explicit time for feedback session, explaining to them how it will run, restating the goals, because it's all role directed. You start with asking the trainee how things went, if it's a week, it's in a week, or it's the end of a case, what went well, what can be improved. And it's not just for the learner, you want to, you know, give them some some input on practice as well. You're going to provide your feedback if it's not previously integrated. And then you're going to co create again, the action steps for improvement. And you're going to agree on next progress check-ins. So it may be, hey, I think I'm getting pretty good at not tying, I don't want you to correct me unless there's a safety issue, I want to keep going. And, you know, check me after I've done a whole line of sutures, don't watch me in each knot. And you know, maybe that's the entrustability or letting them do a whole line of suture, and then you're going to go back instead of checking them on each one. So agree on the appropriate progress. And that gives the learner some space to make their own mistakes and correct their mistakes. So here's some examples. When giving feedback, the language you use is really important to give a message that you think is valuable, and the learner will not kind of dismiss because they don't, they don't like it, they don't like the feeling they get. So key principles, you know, feedback should be descriptive, but not evaluative. Instead of passing judgment, provide clear areas for things that you kind of think fell short. So nice descriptive example, don't say your differential is not very good. You didn't do, it was inadequate. A helpful thing would be your differential did not include the possibility of transverse myelitis or something else, some zebra if you think that's what they should be thinking about. So don't just tell them their differential is adequate. Tell them, be more descriptive about it, okay? Your feedback should be action-based and not making assumptions. You don't necessarily know what the training was thinking or why they considered it. What you do know is the actual outcome, so you focus on the outcome. So your choice of antibiotics, you didn't consider the possibility of XYZ. Well, how do you know they didn't consider it? Well, what you can say is your antibiotic regimen didn't, you know, provide for the coverage of XYZ. So make it based on the action, okay? Feedback shouldn't be super subjective. You know, I felt, it seemed, you should be labeled as such, you know, include an explanation of what led to this. So you looked uncomfortable when you talked about the patient, okay? That, you know, what did that say, you know? How could we say that better? So watching you, I felt you were uncomfortable talking to the patient about X. I noticed you didn't make eye contact and you seemed rushed. So, you know, be a little more clear about things. Yeah, they may have looked uncomfortable, but tell them what you saw and tell them why you think that. And finally, praise, right? We want to sure to give praise when it's warranted, but praise is much more valuable when it's specific. Telling someone their presentation was great, you know, better than, you know, it's not as helpful than telling them why it was great. So you're terrific. You did a great job presenting that case. Not necessarily the best. So tell them what it was. The case presentation gave me a very detailed and useful picture of the patient's problem. That's good praise, right? Nobody likes the praise sandwich. Tell them something good, hit them with something mean, and then tell them something good again. That's not what we're after. We're after feedback that is helpful and it's action-based and less subjective and qualified. Promise we're in the homestretch, y'all. We want to always think about psychological safety in feedback, right? Learning is hard. PA school is hard. NP school is hard. Being a resident is hard. Being a med student is hard. These are all people we're teaching. So some themes you can use to think about it, you know, there really is an association between feedback and psychological safety. And, you know, if we step back and agree that the aim of feedback is to assist learners and to understand what quality works look like and how their work compares by UD standards, we need to use the performance information to kind of implement strategies to improve their performance. But how do you give this feedback in a psychologically safe way? So there's a good study recently in the Journal of Medical Education that tried to answer that question of what psychological safety looks like in the workplace and how feedback, in terms of feedback, and how educators work with learners to foster. So psychological safety in the context of clinical education is really a shared belief that the educator-learner relationship is as safe for interpersonal risk-taking, which creates a sense of confidence that the educator will not embarrass, reject, or punish the learner when there's this mutual respect and trust. And so applying this to feedback interactions, it may be that psychological safety is kind of a key mediator encouraging or discouraging the learner's participation in the feedback process. Authors of this kind of great article asserted if educators work with the learners to maximize their kind of psychological safety, feedback conversations might be transformed. And again, I'm a sports person and a coach, and I always admired this quote from coach John Robinson, who was a coach at USC, a football coach for a long time at UDLV. He said, I never criticize a player until they are first convinced of my unconditional confidence in their abilities. And I just love that, right? If their learner doesn't believe that I believe in them, the feedback that I give them is going to be less psychologically safe. So we need to set a scene for the dialogue and the candor that we're going to provide in our feedback. And they need to see the educator, they need to see me as an ally, and that we support them and we offer reassurance and a system. And a really good way is to lower the power gap. They see us as the person in charge of their grade and their future. So we need to make sure we lower that power gap and maybe let our guard down just a little bit. And importantly, understand it's okay, gaps and mistakes are made when we're learning, and it's our responsibility to not put them in a position where they're going to make bad ones. And, you know, we need to encourage an interactive dialogue and that we share information. They give us their opinion and we give them ours, and that we each respond to each other's comments. So giving feedback that is psychologically safe, very important. So suggested feedback format, I think is, you know, a format we suggest. Kind of six suggested narrative formats, easier to use. And again, we always want this to be a dialogue. So some kind of jumping off points. You know, you want to focus on a goal, and if you don't know, just ask it and it ends with an action plan. So some really things to say to jump off on a feedback session. You know, so far on this, you know, if we're talking at the end of a shift or the end of a case or a day irritation, I noticed you've been focused on blank or observed you doing blank. How do you think you did it? Okay. I think you did well in this case, but I would suggest you work on blank. What do you think? What do you need to improve? How can I help you? Okay. Those are some kind of just have in your pocket things that you can say during a feedback session that will make the session more beneficial. Barriers to receiving feedback, you know, it requires maturity, honesty, commitment to improvement. So business folks who have discovered feedback, note that most of the training around it focuses on the giver and that they, it may enhance the communication and the frequency of feedback, but won't accomplish anything if the receiver is not receptive. So they just, you know, three triggers that block feedback from being absorbed are these triggers, right? So a truth trigger set off by the content of the feedback or the advice when it seemed wrong or unhelpful or exasperates the receiver. And how would you know if this is, you know, occurring? What you can do is you can maybe ask, was my feedback useful? And if there's, you know, if you've offered a psychologically unsafe environment, they can say, well, not really. And you can figure out how to give better feedback. So just ask. There's a relationship trigger and it's tripped when there's no credibility of the giver on the topic or the receiver feels like they have no right to provide the feedback based on the relationship and thus they'll reject the feedback. I think this is probably less likely to happen in this situation, preceptic and neurosurgery. The identity trigger is activated when the feedback causes the receiver's sense of self to come undone. Overly harsh, unreasonable, harsh feedback can really rock a student who are already somewhat a bit vulnerable because again, we talked about school is hard. So these kind of business scholars who have looked at this suggest training on how to give feedback is only one aspect of giving better, being better at giving feedback. Another aspect is for all of us to receive feedback better. So for us to be good givers, we need to be good receivers of feedback. So again, we must be excellent role models. And to do this, separate the message from the messenger. Recognize how you respond to feedback. You get defensive, you get argued, you get silenced. Know your response tendencies. So set aside who is saying it and focus on what is being said. Find a coaching in the criticism. How could paying attention to the feedback help you? Explore where the feedback is coming from. So before you react, ask. Ask where this feedback is coming from in a few more detail to better understand it. Ask for feedback. Ask for it regularly. Getting used to feedback by asking for it often. Make it normal, not stressful. Last, test advice in small experiments. If you doubt something is useful, try it out. Try it out anyway. If it does not work, you can tweak it or decide to end the experiment. So how can we help our trainees be better receivers of feedback? So here are some ideas. Ask them how they have been reacting to feedback in the past. Ask them for themes from feedback they have received over time. Ask them if they ever asked for feedback, specifically if they complain about not getting any. And you might be shocked when you read your evaluations and they say they never got feedback and nobody taught them anything. And ask them what feedback has helped improve their performance the most. So I'd like you to kind of reflect. What are barriers to giving good feedback and how might you overcome them? So I'm asking you to reflect and I'm asking you to come up with a new action plan. So I'm done here. I want to thank you for your time, your interest in thinking about becoming a preceptor and becoming a better teacher in the clinical learning environment. I would again like to thank my colleague, Dr. Dede Herman, GW School of Medicine and Health Science Center for Faculty Excellence for providing content and assisting in creating this lecture. I have a number of references which you can catch in the handout. I thank you very much for your time. I hope you enjoy the rest of the conference.

precepting

advanced practice providers

professional development

mentoring

teaching models

educational programs

feedback delivery

clinical education

learning environment