When I was training (in the early 2000s), program directors and faculty gave the “sandwich feedback.” Essentially, it boils down to…
You are great
But you suck
But no really, you are great
Ok, it wasn’t that specific (you suck), but it was, “You know you have many strengths, but here are some weaknesses I want you to work on, but don’t pay too much attention to what I just said; you are really good.”
I would only pay attention to the middle part because no one was sure that the “bread” in the sandwich was actually “meaningful.” It was not clear whether it was a genuine compliment or said just to soften the blow of the “constructive” feedback
Later, I learned about “goal-oriented feedback,” which I use now. It is a process.
Goal-oriented feedback starts with:
The learner takes the lead in setting an agenda (what they want feedback on, based on their assessment of their own skills and their needs)
The learner tells the observer what to watch for
At the end of the encounter, the observer provides feedback on the observation.
Goal-oriented feedback can be delivered using the SPIKES model.
Steps for using SPIKES to deliver goal-oriented feedback.
Step 1: Set up: Learner sets up the encounter and comes prepared with their goals and a plan on how they wish to accomplish their goal.
Step 2: Perception: The facilitator/observer will ask for not just what to watch for, but also what “success” is defined as and how the learner plans to deal with “conversation not going as planned.”
Step 3: Invitation: At the end of the observation period, the observer will ask if they can provide feedback.
Step 4: Knowledge: the observer will first ask for reflection from the learner about what they had planned to do, how they had planned to do it, and how they thought it went. They will probe further with questions like, what worked? What did not work? And most importantly, “Why do they think it worked/did not work?”
Step 4a: It is likely that the learner had identified the observers’ observations, and there is little to say. If there are observations not stated by the learner, then the observer can provide specific feedback.
Step 5: Empathy: This process is carried out with care and focus on the learner to ensure they feel supported.
Step 6: At the end of the process, have the learner summarize their learning.
So, this is the first example of how SPIKES and NURSE can be used to conduct a different “difficult” conversation.
To get the most out of this Substack and improve the odds of having more meaningful conversations, the learners should combine deliberate practice principles with goal-oriented feedback.
The first step is to identify your goals (what are some specific skills you want to focus on?
The second step is to develop a plan on how to accomplish your goals (what does success look like, what do you anticipate the challenges to be, and how do you plan to address or if possible, prevent the challenges?
The third step is to find an observer and ask them for help in your learning process.
These steps are part of continuous learning and improvement.
Even today, after about 20 years of practice, I use observations from my learners to work on my own skills. An example: I had a challenging case today where I was evaluating and patient with bipolar disorder and related challenge of tangential thought process. I told the student that my plan was to listen first, to understand his concerns and why those are his concerns. Then, it was to inform him of my advice based on his concerns. I planned to use various techniques, including open-ended questions at first and then close-ended ones to help focus the conversation.
At the end of the interview, I reviewed my goals and plan and asked her to give me feedback based on what she observed. It was helpful for me to hear her perceptions. I hope it was helpful for her learning too.
Starting next week, I will share a set of assignments based on SPIKES and NURSE to deliberately practice your skills. It will also begin the interactive portion of the “meaningful conversations.” I encourage you to share your goals for the week with your colleagues (or, if you are comfortable, here in the comments section). Share your reflections again at the end of an encounter, a day or week where you have practiced the skills.
There will be challenges, failures, and successes. Learning communication skills is a process. Active reflection on how things went and why things did not go as planned (or went as planned) is a key to learning.
Wishing you the very best in your journey,
Biren Saraiya MD
As always, I welcome your thoughts, comments and reflections. If you want to share them privately, reach out at meaningfulconversations2024@gmail.com. I will try my best to comment on your reflections and messages.