Active learning is increasingly used as a teaching method in modern medical curricula. Therefore I have adopted case-based group discussions as an educational method for nephrology bedside teaching. In these sessions the students had first to review the patient's history from the case record and summarise the important and vital points. This was followed by a group discussion focusing on the management plan during an outpatient consultation or hospital admission. Through the discussions I got to know the students’ thoughts on the management of the case in question and provided them with feedback.
The majority of students enjoy case-based group discussions, a fact reflected in the students’ evaluation forms. However, a sizable minority find them stressful which may be directly related to my way of delivering feedback. Sometimes I have a tendency to be too blunt in giving the students any negative feedback and this seems to put them off making further contributions to the session.
In searching to learn a better way to give a feedback, I came across an article by Rudolph and colleagues entitled ‘There's no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment’ Citation1. Having read the article I realised the importance of creating a psychological safe teaching environment while challenging the students and engaging them in the discussion. The debriefing model used by Rudolph is based on advocacy and inquiry and giving feedback to the students in a respected way.
The following is an example from my own experience:
Facilitator: A previously healthy patient presents with newly developed swelling in both legs. What is the next step in the management of this patient in the primary health care centre?
Student: Prescribing diuretic therapy and arranging echocardiography.
Facilitator: Your approach is wrong and it is already mentioned in the previous lecture that urine dipstick should be examined in all patients with newly developed lower limb oedema!
Student: One primary physician said that he had never seen a patient with nephrotic syndrome. As it is a rare disease, students should not think about it (A typical self-defence approach). In some other examples the students became red faced and stop contributing to the rest of the session.
Outcome: The facilitator failed to create a safe teaching environment and his/her knowledge was not transferred to the students.
Facilitator: A previously healthy patient………….
Student: Prescribing diuretic therapy and arranging echocardiography.
Facilitator: Fine, you are worried about heart failure. However, it may take months to get echocardiography and the patient may come to harm while waiting. Is there any alternative cause of lower limb oedema?
Outcome: A friendly debate about the management approach of lower limb oedema led to nephrotic syndrome coming up as a possible cause of the patient's problem and performing a simple test, urine dipstick for albumin, in the primary health care centre. A similar technique was used for the rest of the discussion about the management of nephrotic syndrome.
1 Discussion
One of the missions of clinical teaching is to enhance a safe patient management by finding the thinking frame of students. To be able to do so, the teacher should first bring up what the students are taking for granted, considered as correct approach. Then the teacher should be able to suggest a proper approach and give feedback in a safe atmosphere.
To judge and criticise the student's wrong action or answer is clearly not useful (the first example). Ridiculing the student (intentional or non-intentional) in front of his/her peers damages the teaching process, the students lose interest in the case discussion and end up with a poor learning outcome.
Without criticising the student for missing the urine dipstick (the second example), the facilitator was able to share his thoughts and comments with the student in a safe teaching environment with a much better learning outcome.
This approach of constructive feedback ‘debriefing with good judgement’ values the expert opinion of the facilitator (teacher) and helps the students to learn the subject and improve the professional skills.
Omran Bakoush
Department of Nephrology, Clinical Sciences
University Hospital of Lund
S-221 85 Lund, Sweden
Email: [email protected]
Reference
- Rudolph JW, Simon R, Dufresne RL, Raemer DB. There's no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006; 1: 49–55.